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has in fact succeeded in achieving the objective of international comparability&#46; Data from GBD 2010 went a long way to increasing knowledge of global&#44; regional and national health profiles and were a valuable aid for a comprehensive and innovative rethinking of the overall health of populations&#46; With advances in methodology leading to more robust measures and the continuing partnership between The Lancet and the IHME for publication of GBD 2013 and GBD 2015&#44; these updated estimates of disease burden worldwide &#40;all-cause mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> DALYs&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> YLDs<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and risk factors<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a>&#41; constitute an important health information resource&#46; They are not only an essential tool for quantifying global progress in health&#44; but also enable performance to be measured&#44; lacunae to be identified and new priorities to be defined in each country&#44; as well as helping government policy-makers&#44; non-governmental organizations&#44; the medical community and other stakeholders to improve public health&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">While research on burden of disease in Portugal is limited&#44; various studies have contributed to the evidence base and enriched the debate on ways to improve health&#44; particularly in the case of hypercholesterolemia<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and atrial fibrillation&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> as well as the burden of disease&#44; both overall<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> and attributable to risk factors<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> in the Northern region&#44; which have revealed new needs and health problems and influenced regional and local health planning&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The article by Henriques et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> confirms that YLLs due to non-fatal ischemic heart disease &#40;IHD&#41; &#8211; myocardial infarction&#44; angina and heart failure &#8211; contribute much more than YLDs to the global burden of IHD in Portugal&#44; as expressed in DALYs&#46; The proportion of DALYs due to YLDs &#40;11&#46;7&#37;&#41;&#44; for both sexes&#44; was similar to the estimate for Western Europe &#40;11&#46;0&#37;&#41; in 2010 and was almost twice the 1990 figure &#40;6&#46;6&#37;&#41;&#44; while globally &#40;21 world regions&#41;&#44; YLDs due to nonfatal IHD accounted for 6&#37; in men and 8&#37; in women&#44; with inequalities between different countries and regions&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> The authors used an established methodology in international studies in this area applied to data from five of the seven Portuguese NUTS II regions&#46; Some limitations of the study indicate the need to strengthen health information systems&#44; such as those related to mortality and the calculation of YLLs&#44; due to the fact that the cause of death in a significant percentage of cases was reported as symptoms&#44; signs&#44; abnormal findings or ill-defined conditions &#40;8&#46;7&#37; in 2013&#41;&#44; which would hinder comparisons if they were excluded from the analysis&#44; or would depend on the validity of the approach used for reclassification of such &#8216;garbage codes&#8217;&#46; Using YLDs as an indicator may underestimate hospitalizations for acute coronary syndromes&#44; because these are included in the hospital morbidity statistics of the national health service but not of those of all Portuguese hospitals&#46; Furthermore&#44; the use of data from studies conducted in another country &#40;Spain&#41; to estimate the prevalence of stable angina and heart failure points up the lack of recent data for Portugal&#46; Given advances in computational analysis&#44; the solution in the future may well be &#8216;big data&#8217;&#44; the use of computer technology to analyze large data sets in a combination of volume&#44; velocity and variety in a way that will bring significant benefits&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Worldwide&#44; from 1990 to 2013&#44; life expectancy at birth increased by 6&#46;2 years &#40;95&#37; confidence interval &#91;CI&#93; 5&#46;6-6&#46;6&#41; and healthy life expectancy at birth rose by 5&#46;4 years &#40;95&#37; CI 4&#46;9-5&#46;8&#41;&#46; This trend was consistent in 21 world regions in 2013&#44; but around an eighth of life expectancy was associated with disability&#46; In Portugal&#44; time lived with disability in 1990 corresponded to 12&#46;5&#37; and 14&#46;0&#37; of mean life expectancy for men and women&#44; respectively&#44; while in 2013 this was 12&#46;9&#37; and 14&#46;7&#37; &#40;approximately an eighth and a seventh&#44; respectively&#44; of life expectancy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Overall health is improving in all countries&#44; but the proportion of disability in the total burden of disease is increasing due to a slower decline in disability than in mortality rates&#46; For example&#44; in 2015&#44; cardiovascular disease &#40;CVD&#41; was the leader in terms of global DALYs for non-communicable diseases &#40;NCDs&#41; &#40;23&#46;5&#37;&#41; and the percentage change from 2005 to 2015&#44; for all age-groups&#44; was 0&#46;1&#44; 11&#46;0&#44; 17&#46;7 and 28&#46;0&#44; respectively&#44; for cerebrovascular disease&#44; IHD&#44; hypertensive heart disease and atrial fibrillation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> CVD was responsible for only 7&#37; of YLDs in NCDs&#44; and the percentage change from 2005 to 2015 was 20&#46;7&#44; 28&#46;0 and 30&#46;2&#44; respectively&#44; for cerebrovascular disease&#44; atrial fibrillation and IHD&#46; These findings reflect aging populations&#44; an epidemiological transition to a predominance of NCDs&#44; and improved socioeconomic conditions&#44; resulting in populations living longer with disabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Despite these advances&#44; health systems are facing new challenges in meeting needs&#44; applying resources and adapting infrastructure to deal with populations who live longer but with disabilities&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">One final observation on the importance of the IHME in quantifying health loss around the world&#46; The GBD project is now a consortium of over 1900 collaborators in 125 countries&#44; who identify the leading health issues in 195 countries and territories&#44; covering more than 300 diseases&#44; injuries and risk factors&#46; It produces the most reliable health statistics currently available&#44; at both national and global level&#44; revealing inequalities and identifying future challenges that will need to be addressed in order to transform the health and well-being of populations&#46; These include how to increase access to quality data for the calculation of DALYs&#44; for both mortality &#40;certification of cause of death&#41; and morbidity&#44; the invisible component of the burden of disease that is difficult to estimate for many diseases and vulnerable to bias and uncertainty&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> as well as how to improve comparative risk assessment &#40;by constructing disease models to estimate the burden of disease attributable to risk factors&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;19</span></a> Another challenge will be to strengthen research into the links between different development aims&#44; in order to measure the effect of factors that have the greatest impact on health and to act according to this knowledge&#46; The GBD study adds to the evidence and whenever its data are updated&#44; it can serve as an audit of global health and of achievement of goals in the future&#44; as expressed in the health-related targets approved by world leaders in the 2030 Agenda for Sustainable Development at the UN in 2015&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> As pointed out by Dr Margaret Chan&#44; the Director-General of the WHO&#44; &#8220;Data on its own won&#8217;t prevent disease or save lives&#44; but it shows where governments need to act to strengthen their health systems and protect people from the potentially devastating effects of health care costs&#46;&#8221;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
The global burden of disease: An information resource for policy-making and evaluation of health interventions
A carga global de doença: fonte de informação para a definição de políticas e avaliação de intervenções em saúde
Evangelista Rocha
Serviço de Cardiologia, Hospital Militar Principal, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The global burden of disease &#40;GBD&#41; is a complementary measure to traditional health statistics such as mortality rates and hospital productivity that do not reflect the impact of non-fatal outcomes of disease or injury over a patient&#39;s lifetime&#46; The first assessment of health-related quality of life was in 1970 with the development of the health status index&#44; but the term quality-adjusted life years &#40;QALYs&#41; was first used in 1976 to denote a health status measure that combined duration and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Designed to overcome certain limitations of QALYs&#44; disability-adjusted life years &#40;DALYs&#41; entered the health lexicon as a measure of the impact of a disease over time&#44; which combines years lost due to disease &#40;YLDs&#41; and years of life lost &#40;YLLs&#41; due to premature death&#46; The latter is calculated on the basis of potential longevity as defined in a standard table of mean life expectancy&#44; adjusted to take account of changing life expectancy rather than the previously used cut-off of 70 years&#44; or 75 years in some countries&#46; YLDs correspond to the number of years lived with disability&#44; the burden of disability being weighted according to disease severity on a scale of 0 &#40;healthy&#41; to 1 &#40;death&#41;&#46; The DALY measure is recommended by the World Health Organization &#40;WHO&#41; and by the World Bank&#44; and was applied in the first Global Burden of Disease study in 1990 and in the World Bank Development Report in 1993&#44; which had considerable impact on health policies by revealing the hidden burden in certain neglected health areas&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of the GBD project is to provide comprehensive health data on diagnoses and trends that are comparable between countries and thereby to aid in policy decisions at global &#40;WHO and United Nations &#91;UN&#93;&#41;&#44; regional and national levels&#46; One of its specific aims was to develop a measure that can be used to assess the cost-effectiveness of interventions&#44; in terms of the cost per unit of disease burden averted&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> However&#44; the central concept of the GBD study is health loss&#44; not loss of income or productivity&#46; The financial costs of illness and their relationship to outcomes &#40;health gains&#41; have not as yet been assessed by the GBD studies&#44; but since health systems are evaluated in terms of access&#44; quality and financial protection&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> they are likely to be included in burden of disease measures in the future&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2010 GBD study<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> used the same approach as the 1990 study but had a wider scope&#44; a large consortium of collaborators&#44; improved methodology and updated data on diseases&#44; risk factors&#44; regions and countries&#46; The project&#44; variously described as &#8220;a superhuman effort&#8221;&#44; &#8220;a way of life&#44; rather than another massive research project&#8221;&#44; &#8220;mission impossible&#8221;&#44; a test of fire and a Herculean task&#44; and which few initially believed would succeed&#44; was coordinated by the Institute for Health Metrics and Evaluation &#40;IHME&#41; at the University of Washington&#44; Seattle&#44; USA&#44; and involved nearly 500 researchers from more than 300 institutions in 50 countries&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> This technical and organizational challenge&#44; based on a measure&#44; the DALY&#44; that encompasses a widely-shared notion of health and using a descriptive epidemiology that enables causes to be deduced for the differences and trends observed&#44; has in fact succeeded in achieving the objective of international comparability&#46; Data from GBD 2010 went a long way to increasing knowledge of global&#44; regional and national health profiles and were a valuable aid for a comprehensive and innovative rethinking of the overall health of populations&#46; With advances in methodology leading to more robust measures and the continuing partnership between The Lancet and the IHME for publication of GBD 2013 and GBD 2015&#44; these updated estimates of disease burden worldwide &#40;all-cause mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> DALYs&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> YLDs<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and risk factors<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a>&#41; constitute an important health information resource&#46; They are not only an essential tool for quantifying global progress in health&#44; but also enable performance to be measured&#44; lacunae to be identified and new priorities to be defined in each country&#44; as well as helping government policy-makers&#44; non-governmental organizations&#44; the medical community and other stakeholders to improve public health&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">While research on burden of disease in Portugal is limited&#44; various studies have contributed to the evidence base and enriched the debate on ways to improve health&#44; particularly in the case of hypercholesterolemia<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and atrial fibrillation&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> as well as the burden of disease&#44; both overall<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> and attributable to risk factors<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> in the Northern region&#44; which have revealed new needs and health problems and influenced regional and local health planning&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The article by Henriques et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> confirms that YLLs due to non-fatal ischemic heart disease &#40;IHD&#41; &#8211; myocardial infarction&#44; angina and heart failure &#8211; contribute much more than YLDs to the global burden of IHD in Portugal&#44; as expressed in DALYs&#46; The proportion of DALYs due to YLDs &#40;11&#46;7&#37;&#41;&#44; for both sexes&#44; was similar to the estimate for Western Europe &#40;11&#46;0&#37;&#41; in 2010 and was almost twice the 1990 figure &#40;6&#46;6&#37;&#41;&#44; while globally &#40;21 world regions&#41;&#44; YLDs due to nonfatal IHD accounted for 6&#37; in men and 8&#37; in women&#44; with inequalities between different countries and regions&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> The authors used an established methodology in international studies in this area applied to data from five of the seven Portuguese NUTS II regions&#46; Some limitations of the study indicate the need to strengthen health information systems&#44; such as those related to mortality and the calculation of YLLs&#44; due to the fact that the cause of death in a significant percentage of cases was reported as symptoms&#44; signs&#44; abnormal findings or ill-defined conditions &#40;8&#46;7&#37; in 2013&#41;&#44; which would hinder comparisons if they were excluded from the analysis&#44; or would depend on the validity of the approach used for reclassification of such &#8216;garbage codes&#8217;&#46; Using YLDs as an indicator may underestimate hospitalizations for acute coronary syndromes&#44; because these are included in the hospital morbidity statistics of the national health service but not of those of all Portuguese hospitals&#46; Furthermore&#44; the use of data from studies conducted in another country &#40;Spain&#41; to estimate the prevalence of stable angina and heart failure points up the lack of recent data for Portugal&#46; Given advances in computational analysis&#44; the solution in the future may well be &#8216;big data&#8217;&#44; the use of computer technology to analyze large data sets in a combination of volume&#44; velocity and variety in a way that will bring significant benefits&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Worldwide&#44; from 1990 to 2013&#44; life expectancy at birth increased by 6&#46;2 years &#40;95&#37; confidence interval &#91;CI&#93; 5&#46;6-6&#46;6&#41; and healthy life expectancy at birth rose by 5&#46;4 years &#40;95&#37; CI 4&#46;9-5&#46;8&#41;&#46; This trend was consistent in 21 world regions in 2013&#44; but around an eighth of life expectancy was associated with disability&#46; In Portugal&#44; time lived with disability in 1990 corresponded to 12&#46;5&#37; and 14&#46;0&#37; of mean life expectancy for men and women&#44; respectively&#44; while in 2013 this was 12&#46;9&#37; and 14&#46;7&#37; &#40;approximately an eighth and a seventh&#44; respectively&#44; of life expectancy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Overall health is improving in all countries&#44; but the proportion of disability in the total burden of disease is increasing due to a slower decline in disability than in mortality rates&#46; For example&#44; in 2015&#44; cardiovascular disease &#40;CVD&#41; was the leader in terms of global DALYs for non-communicable diseases &#40;NCDs&#41; &#40;23&#46;5&#37;&#41; and the percentage change from 2005 to 2015&#44; for all age-groups&#44; was 0&#46;1&#44; 11&#46;0&#44; 17&#46;7 and 28&#46;0&#44; respectively&#44; for cerebrovascular disease&#44; IHD&#44; hypertensive heart disease and atrial fibrillation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> CVD was responsible for only 7&#37; of YLDs in NCDs&#44; and the percentage change from 2005 to 2015 was 20&#46;7&#44; 28&#46;0 and 30&#46;2&#44; respectively&#44; for cerebrovascular disease&#44; atrial fibrillation and IHD&#46; These findings reflect aging populations&#44; an epidemiological transition to a predominance of NCDs&#44; and improved socioeconomic conditions&#44; resulting in populations living longer with disabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Despite these advances&#44; health systems are facing new challenges in meeting needs&#44; applying resources and adapting infrastructure to deal with populations who live longer but with disabilities&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">One final observation on the importance of the IHME in quantifying health loss around the world&#46; The GBD project is now a consortium of over 1900 collaborators in 125 countries&#44; who identify the leading health issues in 195 countries and territories&#44; covering more than 300 diseases&#44; injuries and risk factors&#46; It produces the most reliable health statistics currently available&#44; at both national and global level&#44; revealing inequalities and identifying future challenges that will need to be addressed in order to transform the health and well-being of populations&#46; These include how to increase access to quality data for the calculation of DALYs&#44; for both mortality &#40;certification of cause of death&#41; and morbidity&#44; the invisible component of the burden of disease that is difficult to estimate for many diseases and vulnerable to bias and uncertainty&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> as well as how to improve comparative risk assessment &#40;by constructing disease models to estimate the burden of disease attributable to risk factors&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;19</span></a> Another challenge will be to strengthen research into the links between different development aims&#44; in order to measure the effect of factors that have the greatest impact on health and to act according to this knowledge&#46; The GBD study adds to the evidence and whenever its data are updated&#44; it can serve as an audit of global health and of achievement of goals in the future&#44; as expressed in the health-related targets approved by world leaders in the 2030 Agenda for Sustainable Development at the UN in 2015&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> As pointed out by Dr Margaret Chan&#44; the Director-General of the WHO&#44; &#8220;Data on its own won&#8217;t prevent disease or save lives&#44; but it shows where governments need to act to strengthen their health systems and protect people from the potentially devastating effects of health care costs&#46;&#8221;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Revista Portuguesa de Cardiologia (English edition)
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