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Associate Professor Theo Vos (PPT 1151 KB large file) Associate Professor Theo Vos (PPT 1151 KB large file) Presentation Transcript

  • Making sense of evidence – Burden of Disease, Projections of Burden and Health Expenditure; Opportunities for Prevention Prof Theo Vos Centre for Burden of Disease and Cost-Effectiveness Case-mix conference Adelaide 17 November 2008 University of Queensland School of Population Health
  • Finite resources in health choices inevitable Increasing pressure to justify choices in expenditure
    • Costs health services are rising as % GDP due to:
    • new expensive technologies
    • ageing
    • greater demands from ‘consumers’
    Background
  • Evidence for health policy
    • size and distribution of health problems: burden of disease & projections
    • costs and impact of health interventions: disease costing & cost-effectiveness
    Essential is a universal method to measure health outcomes
  • Burden of disease
  • DALY
    • Disability-adjusted Life Year
    • future stream of life lost due to premature mortality based on life expectancy:
    • Years of Life Lost (YLL)
    • +
    • future loss of 'healthy' life arising from new cases of disabling conditions:
    • Years Lived with Disability (YLD)
  • DALYs by grouped conditions, Australia 2003 0% 5% 10% 15% 20% Cancer Cardiovascular diseases Mental disorders Neurological and sense disorders Chronic respiratory diseases Injuries Diabetes Musculoskeletal disease Genitourinary disease Digestive disorders Congenital anomalies Neonatal conditions Infections Other % of total DALYs Mortality Disability Begg SJ, Vos T, Barker B, Stanley L, Lopez AD (2008). The burden of disease and injury in Australia in the new millennium: measuring health loss from diseases, injuries and risk factors. Medical Journal of Australia, 188:36 – 40.
  • Life expectancy and years lost due to disability by jurisdiction, remoteness and socioeconomic status, Australia 2003 NSW Vic Qld SA WA Tas NT ACT Low Mod low Average Mod high High Major cities Regional Remote 76 78 80 82 76 78 80 82 76 78 80 82 8 9 10 11 8 9 10 11 8 9 10 11 State/Territory SES quintile Remoteness Life expectancy at birth (years) Proportion of life expectancy at birth lost due to disability (%) Begg S, Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW.
  • Life expectancy and years lost due to disability, Indigenous and total Australian population, 2003 Total Australian population 65 70 75 80 8 9 10 11 Life expectancy at birth (years) Proportion of life expectancy at birth lost due to disability (%) 60 12 13 Non-remote Indigenous population Remote Indigenous population Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Aboriginal and Torres Strait Islander people 2003. Brisbane: University of Queensland. LE: 79 LE: 68 LE: 61
  • DALY rates for leading broad cause groups, Indigenous and total Australian population 2003 * Age standardised to the total Indigenous Australian population, 2003 Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Aboriginal and Torres Strait Islander people 2003. Brisbane: University of Queensland.
  • Age-standardised death rates for major causes of death, Australia, 1922–2000 Begg S, Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW.
  • Change in mortality and disability 1993 –2023 100 200 300 400 60 70 80 90 100 Mortality Disability 1993 2023 0 100 200 300 60 70 80 90 100 Rate per 1,000 Age 0 Begg S, Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW.
  • Change in disease burden 1993 –2023 Begg S, Vos T, Barker B, Stanley L, Lopez AD (2007). The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW.
  • Conclusions
    • Major reductions in mortality and disability from:
      • Tobacco-related disease
      • Cardiovascular disease
      • Injuries
    • Much less change in chronic disabling conditions
    • Increase in diabetes as consequence of steady weight gain
    • Increased life span coupled with healthier life <80; downside: >80 accumulation of disability
  • Projections of health expenditure
  • ‘ Australian case study’
    • Report for UN flagship publication: World Economic Survey 2007 with theme on ageing
    • We have good disease projections and health expenditure by same disease categories
    • Only Netherlands has been able to do same disease-by-disease health expenditure projections
    • Does this make difference?
  • Demographic changes 1925-2045
  • Per capita health expenditure by age and sex, Australia, 2000–01 Data from: AIHW (2005) Health system expenditure on disease and injury in Australia, 2000-01. AIHW Cat No HWE 28 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 0-4 5–14 15–24 25–34 35–44 45–54 55–64 65–74 75+ per capita expenditure Male Female
    • Technological change: diagnostics, drugs, procedures
    • Changing medical practice and policy
    • Organisation and financing of health system
    • Intensity or coverage of health services
    • ‘ Excess’ health inflation
    • Changes in population health status
    Non-demographic drivers of change in health expenditure
  • Health expenditure, Australia 2003-2033 as % of projected GDP 0.0 2.0 4.0 6.0 8.0 10.0 12.0 2003 2013 2023 2033 2043 SPH/AIHW (all health expenditure, including private/out-of-pocket Inter-Generational Report: Federal Govt expenditure only PC (State and Federal Govt expenditure) % GDP 9.4 9.2 9.9 10.8 5.7 6.8 7.9 9.0 10.1 4.7 5.1 6.2 7.9 9.9 Begg S, Vos T, Goss J, Mann N (2008). An alternative approach to projecting health expenditure in Australia. Aust Health Rev , 32:148 – 155.
  • Drivers of growth in health expenditure, Australia 2003-2033 0 0 0 2012-13 2022-23 2032-33 -$20,000 $0 $20,000 $40,000 $60,000 $80,000 $100,000 $ million Ageing Population Disease rate Volume per case Treatment proportion Price 0 Change in total expenditure Begg S, Vos T, Goss J, Mann N (2008). An alternative approach to projecting health expenditure in Australia. Aust Health Rev , 32:148 – 155.
  • Growth in health expenditure, by selected disease groups, Australia 2003-2033 Begg S, Vos T, Goss J, Mann N (2008). An alternative approach to projecting health expenditure in Australia. Aust Health Rev , 32:148 – 155.
  • Projected growth in health expenditure, by type, Australia 2003-2033 Cardiovascular 7,905 16,178 105% 99% 133% Neurological 3,982 15,126 280% 235% 294% Respiratory 5,925 12,621 113% 108% 279% Dental 5,097 12,436 144% 144% Musculoskeletal 3,743 9,864 164% 144% 259% Injuries 5,592 9,359 67% 65% 153% Mental 4,304 8,483 97% 89% 167% Diabetes 1,392 6,971 401% 399% 431% Genitourinary 3,060 6,798 122% 121% 223% Cancer 2,808 5,167 84% 83% 194% Maternal & neonatal 2,305 3,252 41% 41% Other 21,220 46,401 119% 114% Total 71,376 162,319 127% 114% 242% Begg S, Vos T, Goss J, Mann N (2008). An alternative approach to projecting health expenditure in Australia. Aust Health Rev , 32:148 – 155. Health health - aged care aged care 2002–03 2032–33 Change Change Change
  • Conclusions
    • Impact of changes in disease epidemiology has only small impact on overall projected health expenditure estimates (favourable trends CVD, tobacco-related disease, injuries partly compensated by increase in diabetes)
    • … . but our disease-specific estimates are much less ‘alarming’ than Treasury/Productivity Commission projections
    • Ageing, population change, increased volume per case and health inflation main drivers of growth
    • Disease specific estimates indicate big shifts in type of services required
  • Risk factors and opportunities for prevention
  • Disease burden attributable to major risk factors, Australia 2003 9.6% 7.8% 7.7% 6.4% 6.6% 3.8% 2.7% 2.7% 2.6% 0.8% 0.5% 0.3% 5.8% 7.3% 7.3% 6.8% 5.8% 0.7% 1.5% 1.2% 1.3% 0.7% 0.7% 1.5% 2.3% tobacco high body mass high blood pressure physical inactivity high cholesterol alcohol occupational exposures illicit drugs low intake fruit & veg air pollution unsafe sex child sexual abuse intimate partner violence % of total burden Males Females osteoporosis 0.1% 0.3%
  • Risk factors
    • Proportion of disease groups explained by combination of 14 risk factors:
      • Cardiovascular disease: 69%
        • IHD 85%
        • Stroke 70%
      • Cancer: 33%
      • Mental disorders: 27%
      • Neurological disorders: <1%
      • Injuries: 32%
  • Prevention of cardiovascular disease and diabetes
    • Major risk factors and interventions:
      • Tobacco
        • lots of cost-effective interventions but still 2.9 million smokers
        • continued expansion of tobacco control measures
        • need for new quit interventions: vaccine?, snus?, ...?
      • Blood pressure & cholesterol
        • Under-utilisation of cost-effective interventions
        • Inefficient use of current resources
      • Body mass, diet & physical activity
        • Weak evidence for (cost-)effectiveness of interventions
        • No change or worsening over time  not contributed to decline in CVD
        • Massive increase in incidence of diabetes predicted while case fatality drops  even bigger increase in prevalence
  • Current practice 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 0 100 200 300 400 500 600 700 Lifetime DALYs averted ('000) Lifetime Costs (million AUS$) community heart health program Diuretic & Aspirin β-blocker Dietitian Phytosterol Statin Ezetimibe Optimal mix of blood pressure and cholesterol-lowering interventions in primary prevention
  • Reasons for inefficiency of current practice
    • Single risk factor thresholds (i.e. high vs normal blood pressure) vs combined ‘absolute’ risk
    • Not enough attention to lifestyle and public health interventions
      • CHHP
      • Dietary counselling
      • Phytosterol supplementation
    • Current resources directed at less efficient classes of BP lowering drugs
      • ACE inhibitors
  • Optimal mix of physical activity interventions -$1,000 -$800 -$600 -$400 -$200 $0 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 Life time DALYs averted Life time costs A$ Millions Including time & travel costs Excluding time & travel costs Pedometers Mass media Internet GP prescription TravelSmart GP referral
  • Comments on physical activity interventions
    • weak evidence
      • Pedometers tested in volunteers
      • Different units of measurement of effect
      • Varies from meta-analyses to single studies with before-after design
    • … but 5 of the 6 interventions could address up to a third of burden from physical inactivity
  • Prevention of cancer
      • Most change over time from tobacco interventions
      • Smaller risk factors: alcohol, air pollution, sun exposure, HPV
      • Screening for breast, cervix, bowel, prostate: modest health gain, relatively high cost
      • A lot of ‘unexplained’ cancer
      • Treatments have at best modest impact on course of most cancers
  • Prevention of mental disorders
    • Substance use:
    • Some reduction in alcohol dependence but not binge drinking
    • Plausible evidence for link heavy cannabis use & schizophrenia
    • Up to a third of alcohol burden can be reduced with a package of six preventive measures
    • Mental disorders:
    • Limited knowledge about prevention of major mental disorders but some ideas being tested for prevention of depression and childhood disorders
    • No evidence for interventions to reduce exposure to child sexual abuse or intimate partner violence
  • Optimal mix of alcohol interventions
  • Prevention of neurological disorders
    • Neurological disorders:
    • Some prospects of treatment/prevention with drugs/vaccine for dementia and Parkinson’s but current ability to prevent is very limited
  • Trends in road accident mortality, Australia 1950-2003 Seat belts RBT Seat belts RBT
  • Trends in homicide & violence mortality, Australia 1950-2003 Port Arthur massacre Port Arthur massacre
  • Conclusions
    • Burden of disease (“how big are health problems, who gets it, and are things changing?”) and cost-effectiveness (“how can we achieve most health gain given a certain budget”) form a powerful set of tools to inform resource allocation decision making in health
    • Requires intensive analytical effort but tools to do so are improving
    • Most immediate additional health gain from ‘past winners’: tobacco control, CVD prevention, injury control
    • Large disease/risk factor areas not well addressed by prevention: obesity, physical activity, neurological conditions, mental disorders, hearing loss, diabetes, asthma  research priorities