Abstract
Background: Previous studies have reported national and regional Global Burden of Disease (GBD) estimates for the UK. Because of substantial variation in health within the UK, action to improve it requires comparable estimates of disease burden and risks at country and local levels. The slowdown in the rate of improvement in life expectancy requires further investigation. We use GBD 2016 data on mortality, causes of death, and disability to analyse the burden of disease in the countries of the UK and within local authorities in England by deprivation quintile. Methods: We extracted data from the GBD 2016 to estimate years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and attributable risks from 1990 to 2016 for England, Scotland, Wales, Northern Ireland, the UK, and 150 English Upper-Tier Local Authorities. We estimated the burden of disease by cause of death, condition, year, and sex. We analysed the association between burden of disease and socioeconomic deprivation using the Index of Multiple Deprivation. We present results for all 264 GBD causes of death combined and the leading 20 specific causes, and all 84 GBD risks or risk clusters combined and 17 specific risks or risk clusters. Findings: The leading causes of age-adjusted YLLs in all UK countries in 2016 were ischaemic heart disease, lung cancers, cerebrovascular disease, and chronic obstructive pulmonary disease. Age-standardised rates of YLLs for all causes varied by two times between local areas in England according to levels of socioeconomic deprivation (from 14 274 per 100 000 population [95% uncertainty interval 12 791–15 875] in Blackpool to 6888 [6145–7739] in Wokingham). Some Upper-Tier Local Authorities, particularly those in London, did better than expected for their level of deprivation. Allowing for differences in age structure, more deprived Upper-Tier Local Authorities had higher attributable YLLs for most major risk factors in the GBD. The population attributable fractions for all-cause YLLs for individual major risk factors varied across Upper-Tier Local Authorities. Life expectancy and YLLs have improved more slowly since 2010 in all UK countries compared with 1990–2010. In nine of 150 Upper-Tier Local Authorities, YLLs increased after 2010. For attributable YLLs, the rate of improvement slowed most substantially for cardiovascular disease and breast, colorectal, and lung cancers, and showed little change for Alzheimer's disease and other dementias. Morbidity makes an increasing contribution to overall burden in the UK compared with mortality. The age-standardised UK DALY rate for low back and neck pain (1795 [1258–2356]) was higher than for ischaemic heart disease (1200 [1155–1246]) or lung cancer (660 [642–679]). The leading causes of ill health (measured through YLDs) in the UK in 2016 were low back and neck pain, skin and subcutaneous diseases, migraine, depressive disorders, and sense organ disease. Age-standardised YLD rates varied much less than equivalent YLL rates across the UK, which reflects the relative scarcity of local data on causes of ill health. Interpretation: These estimates at local, regional, and national level will allow policy makers to match resources and priorities to levels of burden and risk factors. Improvement in YLLs and life expectancy slowed notably after 2010, particularly in cardiovascular disease and cancer, and targeted actions are needed if the rate of improvement is to recover. A targeted policy response is also required to address the increasing proportion of burden due to morbidity, such as musculoskeletal problems and depression. Improving the quality and completeness of available data on these causes is an essential component of this response. Funding: Bill & Melinda Gates Foundation and Public Health England.
| Original language | English |
|---|---|
| Pages (from-to) | 1647-1661 |
| Number of pages | 15 |
| Journal | The Lancet |
| Volume | 392 |
| Issue number | 10158 |
| Early online date | 24 Oct 2018 |
| DOIs | |
| Publication status | Published - 3 Nov 2018 |
Funding
The GBD 2016 database development, methods improvement, and global analysis is primarily funded by the Bill & Melinda Gates Foundation, which had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all data in the study and had final responsibility to submit the paper. Overall, the results suggest that all countries of the UK could further reduce the burden of disease through effective prevention. For example, the continued dominance of cardiovascular disease in GBD argues for renewed efforts to deliver systematic programmes to reduce risk factors, such as high body-mass index, high fasting glucose, high blood pressure, and high cholesterol. Other conditions that feature highly in GBD estimates for the UK (such as cancers and respiratory disease) can be addressed by tackling specific behaviours, such as smoking and eating unhealthy foods. Good progress has been made in some areas, notably in reducing the prevalence of smoking to historic lows in all countries of the UK, but there is scope to do so much more in almost all areas of primary prevention. Two-thirds of the improvements to date in premature mortality can be attributed to population-wide decreases in smoking, cholesterol, and blood pressure, and about a third are due to improved therapies. 59 Health services need to recognise that prevention is a core activity rather than an optional extra to be undertaken if resources allow. In many cases, the causes of ill health and the behaviours that cause it lie outside the control of health services. For example, obesity, sedentary behaviour, and excess alcohol use all feature strongly in GBD as risk factors for diseases such as musculoskeletal disease, liver disease, and poor mental health. The GBD results, therefore, also argue for policies and programmes that deter the food industry from a business model based on cheap calories, that promote and sustain healthy built and natural environments, and that encourage a healthy drinking culture. The same level of attention that has previously been given to prevention of cardiovascular disease and cancer now needs to be directed at the other major causes of YLLs, such as liver disease and dementia, and associated risk factors, including unhealthy diets, alcohol, air pollution, and drug misuse. Adequate research on effective population-level prevention interventions in these areas is scarce, but not absent. Public health policy needs also to respond actively and rapidly to the shift in relative burden from mortality towards morbidity. More evidence is needed to support population-level interventions to address the causes and effects of conditions such as musculoskeletal disease, poor mental health, and sensory impairments, and research and action is urgently needed to prevent further increases in burden due to disability from these conditions, and to understand the economic impact. Timely access to health services is important for treatable conditions such as vision loss caused by cataract, glaucoma, and diabetic retinopathy. The promotion of musculoskeletal and mental health are key components of the recent WHO Europe Action Plan for Noncommunicable Disease to avoid premature death and substantially reduce disease burden. 60 There are still concerns with the accuracy of local estimates of ill health, but the hierarchical ranking of YLD by Upper-Tier Local Authority can inform better local targeting of health services. For future iterations of GBD, the use of primary care electronic health records, including prescribing, should be used to refine disease prevalence estimates and improve consistency between GBD and other reliable estimates, while recognising that utilisation rates have known weaknesses as measures of need. 61 Data for health-care utilisation remain underutilised for descriptive epidemiology. Their value can be enhanced if linked to population survey data and death records because the strengths of each data type (good diagnostic information in health records, data on risk factors and severity of disease from surveys) enhance their value as a measure of population health. There are excellent examples of data linkage for audit (eg, the Sentinel Stroke National Audit programme), research (eg, the Caliber project at University College London), and policy (eg, NHSDigital linked hospital and mortality data), but still no linked health data that can inform comparable estimates of burden of disease at the local level. Further research on disease burden at the Upper-Tier Local Authority level should explore the burden of different diseases according to specific diagnoses and explore the effect of age disaggregation (eg, in children and in different age groups for older people). Overall, this study provides timely estimates that can inform the new long-term plan for the NHS in England and similar planning processes in the countries of the UK, and at local level in England. The new local estimates will increase the relevance of GBD for many users, highlighting where local levels of burden and risk factors might require tailored local solutions—for example, for diet and occupational risks ( appendix pp 35–44 ). National results reveal the need for effective primary prevention to reduce the substantial attributable risks due to smoking, unhealthy diets, obesity, and excess alcohol use, which lead to massive burdens from heart disease, cancer, and various comorbidities that reduce independence in older people. Resource allocation in health services needs to continually adapt to the increasing burden from non-fatal conditions, such as musculoskeletal conditions, depressive disorders, sensory loss, and skin diseases. Substantial improvements in the quality and completeness of available morbidity data are needed to support the implementation of such a change in national health policy. We hope that this study will inform similar analyses across Europe supported by the newly formed WHO European Burden of Disease Network. 62 This online publication has been corrected. The corrected version first appeared at thelancet.com on October 26, 2018 Contributors NS, JAF, and JNN wrote the first draft of this manuscript. JNN, ACJD, and CJLM conceived the idea for the study and provided overall guidance. All other authors provided data, developed models, reviewed results, initiated modelling infrastructure, or reviewed and contributed to the report. Declaration of interests RWA reports grants from Wellcome Trust during the conduct of the study. CC reports personal fees from Alliance for Better Bone Health, Amgen, Eli Lilly, GlaxoSmithKline, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda, and UCB, outside the submitted work. ME reports a charitable grant from AstraZeneca's Young Health Programme, and personal fees from Prudential, Scor, and Third Bridge, outside the submitted work. JAF reports grants from Public Health England during the conduct of the study. FK reports non-financial support from Queens University Belfast during the conduct of the study. HJL reports financial support from GlaxoSmithKline, outside the submitted work. RAL is supported by the Farr Institute. The Farr Institute is supported by a 10-funder consortium: Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute of Health Research, the Health and Care Research Wales (Welsh Assembly Government), the Chief Scientist Office (Scottish Government Health Directorates), and the Wellcome Trust, (Medical Research Council grant number MR/K006525/1). AM's institution (Imperial College London) receives financial support from the NW London National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research & Care. HR reports grants from the London School of Hygiene & Tropical Medicine during the conduct of the study. LS reports grants from Wellcome during the conduct of the study; grants from Wellcome, Medical Research Council, NIHR, British Heart Foundation, and Diabetes UK, outside the submitted work; grants and personal fees from GSK; and is a Trustee of the British Heart Foundation. NS reports grants from Public Health England during the conduct of the study. RMV is President of the Royal College of Paediatrics & Child Health and is a member of the Lancet Commission on Adolescent Health. AW reports grants from Pfizer and non-financial support from Grunenthal, outside the submitted work. All other authors declare no competing interests. For the data used in these analyses, please visit GBD compare at https://gbd2016.healthdata.org/gbd-compare . To download the data used in these analyses, please visit the GBD 2016 Results Tool at https://gbd2016.healthdata.org/gbd-results-tool . Acknowledgments We thank Elizabeth Lenaghan for project support to the University of East Anglia and Public Health England GBD team, Meghan Mooney for leadership of the Institute for Health Metrics and Evaluation UK liaison team, Julia Gall for project support to the Institute for Health Metrics and Evaluation UK liaison team, and Hannah Gregory for editing of the manuscript. Harry Rutter was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust (NIHR CLAHRC North Thames). The views expressed in this Article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.
ASJC Scopus subject areas
- General Medicine
