where does arthritis fit Associate Professor Fiona Blyth MBBS Hons FAFPHM PhD In this talk Introduction how epidemiology contributes to advocacy History from stigma and judgment to human rights ID: 390812
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Slide1
Global Burden of Disease – where does arthritis fit?
Associate Professor Fiona Blyth
MBBS (Hons) FAFPHM, PhDSlide2
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide3
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide4
Why we need good information about arthritis in the population
To get visibility as a health care problem
To compete with other more ‘established’ conditions for limited health resources
To highlight areas of unmet need
To have the opportunity to learn about those who are ‘doing well’ with arthritisSlide5
What do epidemiologists have to do with it?
We look at the size, patterns, causes and consequences of health problems in population groups
This can help to lobby for extra resources by providing a shape and form for health problems
It can help gauge how advances developed in specialised settings might translate “out there” in the communitySlide6
Putting it together…adapted from Blyth 2010
ARTHRITIS-FOCUSSED
STUDIES
GENERAL HEALTH
SURVEYS
RISK FACTORS/
BURDEN
WITHIN
SPECIFIED
POPULATIONS
HOW COMMON/
SEVERE IS
ARTHRITIS
COMPARED WITH
OTHER
CONDITIONS?
Shape
Place
VoiceSlide7
Giving arthritis and musculoskeletal problems a voiceSlide8
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide9
History has some lessons for us-1
The Lancet, 1932Slide10
Sound familiar?
‘The reasons for dealing with chronic rheumatism systematically on a national scale include the following…
The disease at present causes a large loss in money, and an immense amount of preventable suffering and
crippledom
.
Nothing systematic is at present being done in England, whereas, other countries e.g. Germany and Sweden – find it worth their while to tackle the problem.
Lay opinion is in favour of action, but lacks medical guidance, while research, which is very desirable in this group of diseases, could be stimulated and rendered possible on a larger scale than at present.’
Copeman
, Lancet 1932Slide11
Hmmm…
‘Research is an urgent need in this branch of medicine. The subject of chronic rheumatism has never, until recently, inspired enthusiasm, except in few individuals, and is therefore most neglected
’
Copeman
, Lancet 1932Slide12
Here comes the competition!
Lastly, it is suggested that possibly other diseases should also be singled out for special treatment.
But such a scheme is necessary only in the case of
a chronic disease which occurs on a scale large enough to merit the title of a social menace
.
These diseases are four in number
Copeman
, Lancet 1932Slide13
Tuberculosis – Efficient scheme already in force.
Venereal diseases – Efficient scheme already in force.
Cancer – Owing to dramatic appeal of this disease adequate voluntary effort is forthcoming.
Chronic rheumatism – The most costly of the three (to the country), but lacking in dramatic appeal because it is not fatal. Scheme suggested
Copeman
, Lancet 1932
.Slide14
1944
25 soldiers with backache/no organic signs
British army hospital in Italy
‘
Biopsychosocial
’ assessment
British Medical Journal 1946
History has some lessons for us
-2Slide15
Psychological assessment Paulet, BMJ 1946
“Four patients had an immature personality; they were shy mother-fixated emotionally adolescent male virgins”
“Of the 25 patients, 20 had an inadequate personality. Those who habitually interpret their failures as due to circumstances unjustly thrust upon them, may reach a quasi-paranoid state, losing the self-criticism that is essential for social harmony”Slide16
Paulet, BMJ 1946
“it is hard for a simple-minded hypochondriac to adopt any other attitude than that he has been unjustly accused of malingering. If he had no psychological disability before this event, he would certainly have one after it”
“The mechanism of low back pain remains obscure”
Stigmatized and judgedSlide17
2010 Declaration of MontrealSlide18Slide19
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide20
Why is the Global Burden of Disease important?
Changing global demography
Changing global economy
Changing patterns of disease and disability
Need for a comprehensive and systematic revision of global burden of disease estimatesSlide21
The World by land area(Worldmapper http://www.worldmapper.org
/)Slide22
The world sized by population aged over 65 years (Worldmapper)Slide23
The world sized by global burden of diabetes (Worldmapper) Slide24
The world sized by global spending on public health (Worldmapper)Slide25
The funding hasn’t followed this rapid change...Stuckler et al, Lancet 2008
Chronic diseases
Chronic diseasesSlide26
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide27
Burden of DiseaseBurden of Disease is a way of measuring and ranking the effects of diseases on the health of
populations
Two parts to this: death and disability (and both combined)
27Slide28
Impact of previous GBD findingsHighly influential
Stimulated
national burden of disease
studiesinformed governmental and non-governmental priorities for research, development, policies and healthcare funding
28Slide29
GBD 2010 Overall Aims
To produce new, robust, and reliable estimates of burden for all major diseases, injuries, and risks that are
widely disseminated, understood, and easily used by policymakers, researchers, funders and practitioners.Slide30
GBD
2010
started in 2008
Major findings published in December 2012 in The Lancet
M
ore than 175
diseases and injuries, 20 risk
factors
More than 400 experts around the world
involved
GBD 2010Slide31
GBD 2010globalburden.org
Key collaborators:
Johns Hopkins University
Harvard University
University of Queensland*
Institute for Health Metrics and Evaluation at the University of Washington
World Health OrganizationSlide32
Musculoskeletal conditions in GBD: evolution over time
Osteoarthritis (GBD
1990
,
2000
,
2010
)
Rheumatoid arthritis (GBD
1990
,
2000
,
2010)Low Back pain ( LBP in GBD 2000
, 2010)Neck Pain (GBD 2010)Gout (GBD 2010)Other MSK (GBD 2010)Slide33
Brief overview of what was doneEach expert group found all the relevant studies in their disease area over a fixed time period around the world and assessed them (quality, main findings)
Each group then had to work out the main common patterns of this disease from the available studies (e.g. acute, chronic, mild, severe, short-term, long-term, mortality)
The next task was to measure how much disability occurred with these common patterns: DIFFICULT!
All this information was put together (very complicated!) by a central coordinating team based in the USA (the Core Team) to produce rankings of diseases according to deaths caused, disability caused and combined death and disability (=BURDEN OF DISEASE)
33Slide34
How was disability measured?For each common pattern of each disease:
A simple (lay) description of what a person in this state would experience was developed
People in different countries were asked to make comparisons between two descriptions for two conditions – these were used to assess how disabling all patterns of all diseases were (‘disability weights’)
34Slide35
The first set of questions asks about
capacity in different areas of functioning
. Indicate by checking either ‘yes’ or ‘no’ whether a person would be able to perform the following functions.
Rising: Rise from lying position on the ground (Yes/No); Rise from sitting position on the ground (Yes/No)
Building a lay description from the Health State ChecklistSlide36
The second set of questions asks about specific symptoms or problems. Indicate by checking either ‘yes’ or ‘no’ whether a person would experience the symptom or problem, and indicate average duration and/or frequency where relevant
Feeling worried or anxious (Yes/No; # days per week;# hours per day)
Building a lay description from the
Health
State
ChecklistSlide37
Quite a process!
Final versions had to be concise
Modified after feedback from
GBD
central team which had
oversight
of all disease groups
Major restrictions on both
length
and content
WHY BOTHER?Slide38
The final lay descriptions - LBP
ACUTE BACK PAIN WITH LEG PAIN
- “person with severe back and leg pain”
This person has severe back and leg pain, which causes difficulty dressing, sitting, standing, walking, and lifting things. The person sleeps poorly and feels worried
.
CHRONIC LOW BACK PAIN WITH LEG PAIN
- “person with constant back and leg pain”
This person has constant back and leg pain, which causes difficulty dressing, sitting, standing, walking, and lifting things. The person sleeps poorly, is worried, and has lost some enjoyment in life.
Slide39
OsteoarthritisLay Definitions
39
MILD OA
-
“the person with the mild pain and stiffness in the legs”
This person has moderate pain and stiffness in the legs which causes difficulty running, walking long distances and getting up and down.
MODERATE OA -
“the person with the moderate pain in the hips &/or knees”
This person has moderate pain in the leg, which makes the person limp, and causes some difficulty walking, standing, lifting or carrying heavy things and getting up and down and sleeping.
SEVERE OA -
“the person with the severe constant pain in the hips &/or knees”
This person has severe pain in the leg, which makes the person limp and causes a lot of difficulty walking, standing, lifting and carrying heavy things, getting up and down, and sleeping
.Slide40
Survey webpage http://gbdsurvey.org/Slide41Slide42Slide43
New and important addition to this processPeople in developing countries were also asked to do the same ratings in
household
surveys (
Bangladesh, Indonesia, Peru, South Africa, Tanzania; USA to compare)Interestingly, the results were quite similar across countries
Previous GBD studies had relied on experts
43Slide44
‘Democratization of data’
Open access data visualisation tools rapidly made available on Institute of Health Metrics Evaluation website:
http://www.healthmetricsandevaluation.org/gbd/visualizations/countrySlide45
http://
www.healthmetricsandevaluation.org/gbd/visualizations/countrySlide46
Musculoskeletal conditions
Widespread recognition of the huge disability burden globally and locally related to MSK conditions (NB low back pain, neck pain)
Surprisingly low disability weights for osteoarthritis
Significant gaps in basic information from many countries
Lack of consistent data needs to be addressed in the future (
eg
, severity and length of episodes)Slide47
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide48
Musculoskeletal problems matter early in life
K
ey findings from epidemiological studies of pain in childhood and adolescence
Pain is common in childhood and adolescents, shows evidence of common underpinnings, and seems to have distinctive trajectories over time
Key findings from birth cohort studies of experiences early life influence later health in adulthood
Broad, subtle and pervasive effects on musculoskeletal health happen early in life
Big potential for gains in years lived without pain disabilitySlide49Slide50
Key findings
Working age people with long-term back problems were more than two and a half times more likely not to be in the labour force
With three or more additional conditions, this goes up substantially – more than nine times more likely not to be in the labour force
Early retirement due to back problems will substantially reduce accumulated wealthSlide51
The bigger picture of health and ageingSlide52
National GP survey
GP consultations
GP assessment of morbidities (CIRS)
Common patterns of multimorbiditySlide53
What about arthritis?
Britt et al, MJA 2008Slide54
In this bigger picture, how important
are MSK conditions?Slide55
Very!Slide56
Greatest impact
“In light of the variability in methods of prior studies, it is striking that previous studies have also ranked musculoskeletal disorders and major depression as the conditions associated with the largest number of disability days at both the individual
and population levels.” (Merikangas
et al, 2008)Slide57
Comorbidity and Multimorbidity occurs in older people but…Slide58
What do we REALLY know about the ageing process and how it relates to diseases, their causes and consequences?
“A glass of sherry a day keeps me going”
quoted
103 year old Daphne Timms.
The Warrnambool Standard, VIC, Aust.Slide59
Eva follows the “risk factor script”...
Eva McConnell, 110, is now Australia’s oldest person. Eva attributes her longevity “to hard work and plain tucker.” Eva was still living on her own, cooking for herself and chopping wood when she turned 100.
Ulladulla Times, NSW, Aust.Slide60
Uh-oh...
Lorna
Gobey
, a 100-year old woman says drink and cigarettes keep her young. She has smoked over half a million cigarettes and still smokes 20 cigarettes a day. “I like my smokes, a drop of whiskey and Guinness and I still love to play skittles”. She attributes her longevity to her fun-loving lifestyle.The Telegraph, U.K.Slide61
In this talkIntroduction – how epidemiology contributes to advocacy
History: from stigma and judgment to human rights
The big picture of Global Health
GBDSome important considerations across the lifespanAdvocacySlide62
Conclusion
A clearer picture is emerging of the heavy global and national toll of MSK conditions
Important that it is used to argue for resources
Also important to keep up the ‘back room’ efforts to improve how this burden is measuredSlide63
What do we need to do?Train for a marathon and not a sprint
Improve measures, measurement and surveillance at population levels
Think about risk and prevention as well as treatment
Think about risk in relation to all levels of prevention
Think globally and act collaboratively
Advocate