Lancet. 2017 Sep 16;390(10100):1260-1344. doi: 10.1016/S0140-6736(17)32130-X.
BACKGROUND: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. FINDINGS: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. INTERPRETATION: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. FUNDING: Bill & Melinda Gates Foundation.
背景:衡量不同地点的健康变化有助于比较和对比不断变化的流行病学模式与卫生系统绩效,并确定在研究、政策制定和规划决策中资源分配的具体需求。我们利用全球疾病、伤害和危险因素研究 2016 年的数据,从两个广泛使用的综合指标中提取数据,以监测人口健康方面的此类变化:伤残调整生命年(DALYs)和健康期望寿命(HALE)。我们使用这些指标来跟踪趋势,并根据社会人口指数(SDI)的预期趋势进行基准比较。
方法:我们利用全球疾病、伤害和危险因素研究 2016 年的所有原因死亡率、特定原因死亡率和非致命性疾病负担的数据,为 195 个国家和地区计算了 1990 年至 2016 年期间的两性 DALY 和 HALE。我们通过为每个地点、年龄组、性别和年份计算失去的生命年和残疾生活的生命年来计算 DALY。我们使用特定年龄的死亡率和人均残疾生活年数来估计 HALE。我们探讨了 DALY 和 HALE 与 SDI 相比如何出现偏离预期的情况:SDI 是指人均收入、15 岁以上人口的教育程度和总生育率的几何平均值。
结果:全球范围内女性和男性的出生时 HALE 最高的是新加坡,分别为 75.2 岁(95%不确定区间为 71.9-78.6)和 72.0 岁(68.8-75.1)。女性中最低的是中非共和国(45.6 岁[42.0-49.5]),男性中最低的是莱索托(41.5 岁[39.0-44.0])。1990 年至 2016 年期间,全球 HALE 平均增长了 6.24 岁(5.97-6.48),两性均有所增加。男性 HALE 增长了 6.04 岁(5.74-6.27),女性增长了 6.49 岁(6.08-6.77),而 65 岁时的 HALE 男性增长了 1.78 岁(1.61-1.93),女性增长了 1.96 岁(1.69-2.13)。1990 年至 2016 年期间,全球 DALY 总数基本保持不变(-2.3%[-5.9 至 0.9]),传染性疾病、孕产妇、新生儿和营养(CMNN)疾病的 DALY 减少被非传染性疾病(NCD)的 DALY 增加所抵消。以 2016 年观察到的年龄标准化 DALY 率与预期比率最低的五个比值为代表的例子是尼加拉瓜、哥斯达黎加、马尔代夫、秘鲁和以色列。全球 DALY 排名前三位的原因是缺血性心脏病、脑血管病和下呼吸道感染,占所有 DALY 的 16.1%。1990 年至 2016 年期间,CMNN 大多数病因的 DALY 总数和年龄标准化 DALY 率下降。相反,大多数 NCD 的 DALY 总负担上升;然而,全球 NCD 的年龄标准化 DALY 率下降。
解释:在全球范围内,DALY 和 HALE 继续显示出改善。与此同时,我们观察到许多人群正面临着日益严重的功能健康损失。随着 SDI 的上升,累积的残疾生活年数增加,CMNN 的 DALY 减少被 NCD 的 DALY 增加所抵消。发病率的相对压缩突出了继续进行健康干预的重要性,这在大多数地方都随着人均国内生产总值、教育和计划生育而变化。DALY 和 HALE 及其与 SDI 的关系的分析代表了一个稳健的框架,可以对特定地点的健康绩效进行基准比较。疾病负担的特定驱动因素,特别是那些 DALY 高于预期的原因,应该为卫生政策、卫生系统改进举措、有针对性的预防工作以及包括所有国家在内的卫生发展援助提供信息,无论其社会人口发展水平如何。存在表现明显优于其他国家的国家表明,需要对经过验证的最佳实践进行更严格的审查,以帮助扩大收益,而存在表现不佳的国家则表明需要更加关注需要更有力支持的卫生系统。
资金:比尔及梅琳达·盖茨基金会。
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