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DYNAMO-HIA – International experiences, results & further perspectives.Workshop-documentation,27-28May2015,Bielefeld,DE.

DYNAMO-HIA – International experiences, results & further perspectives.Workshop-documentation,27–28May2015,NRWCentreforHealth,Bielefeld,Germany.

LandeszentrumGesundheitNordrhein-Westfalen

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LZG.NRW

DYNAMO-HIA – International experiences, results & further perspectives

Impressum

LandeszentrumGesundheitNordrhein-Westfalen(LZG.NRW)Gesundheitscampus-Süd944801BochumTelefon: 023491535-0Telefax: [email protected]

RedaktionMonikaMensing(LZG.NRW)OdileMekel(LZG.NRW)

NamensbeiträgegebendieMeinungenderVerfasserwieder.SieentsprechennichtunbedingtderAuffassungdesHerausgebers.

LayoutundVerlagLZG.NRW

BildnachweisTitelbild:dima_pics-Fotolia.de,Seite10:PiotrWawrzyniuk-Fotolia.de

DasLZG.NRWisteineEinrichtungdesLandesNordrhein-WestfalenundgehörtzumGeschäftsbereichdesMinisteriumsfürGesundheit,Emanzipation,PflegeundAlter.NachdruckundVervielfältigung,auchauszugsweise,nurmitQuellenangabegestattet.

Bielefeld,August2016

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DYNAMO-HIA – International experiences, results & further perspectives DYNAMO-HIA–Internationalexperiences,results&furtherperspectives

Contents

DYNAMO-HIA Workshopobjectivesandagenda.................................................................................................... 7

WelcomeTheNRWCentreforHealth:overviewofactivitiesrelatedtoHIAandHIQOdileMekel........................................................................................................................................ 9

BMI prognostic modelling PotentialhealthgainsintheelderlypopulationofNRWMonikaMensing..............................................................................................................................10

Modelling effects of nutrition improvements on health outcomes Johanna-KatharinaSchönbach&StefanK.Lhachimi.................................................................. 11

Modelling the effects of intervention and policies onDisability-FreeLifeExpectancyusingDYNAMO-HIAWilmaJ.Nusselder..........................................................................................................................13

The effect of traffic-related air pollution on respiratory diseases inthemunicipalityofCopenhagen(DK)HenrikBrønnum-Hansen................................................................................................................15

The health impact of interventions on selected risk factors inthemunicipalityofCopenhagen(DK)HenrikBrønnum-Hansen................................................................................................................ 17

Using DYNAMO-HIA batch-mode to perform probabilistic uncertainty analysis TheexampleofmodellinghealthimpactsofdietarysaltreductionHendriekC.Boshuizen....................................................................................................................18

Future perspectives......................................................................................................................19

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7 DYNAMO-HIA – International experiences, results & further perspectives

DYNAMO-HIA Workshopobjectivesandagenda

InMay2015,theNRWCentreforHealthhosteda2-dayscientificexpertworkshopondynamicmodelling,toquantifythehealthimpactofpoliciesinfluencinghealthdeterminants.Interna-tionaldevelopersaswellasusersofthesoftwaretool“DYNAMO-HIA”(aDYNAmicMOdelforHealthImpactAssessment)wereinvitedtodiscussmodellingapproaches,riskassessmentandresultsindifferentcountriesandsettings,addresstechnicalissuesoftheinstrument,exchangeexperiencewithcontributingtopolicy-makingprocessesandenvisagingfutureper-spectives,likecooperationalprojectsandjointdatabases.

Participants(fromlefttoright):OdileMekel(NRWCentreforHealth,Bielefeld,D),HendriekC.BoshuizenandKoenFüssenich(bothRIVM,Bilthoven,NL),HenrikBrønnum-Hansen(UniversityofCopenhagen,DK),MonikaMensing(NRWCentreforHealth,Bielefeld,D),WilmaNusselder(ErasmusMC,Rotterdam,NL),FlorianFischer(UniversityofBielefeld,D),JohannaSchönbachandStefanK.Lhachimi(BIPS/UniversityofBremen,D).

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DYNAMO-HIA: International experiences, results & further perspectives 27th – 28th May 2015

NRW Centre for Health

Penthouse Westerfeldstr. 35/37, D-33611 Bielefeld

Tel.: +49 (0) 521-8007-3252

Workshop – Agenda

Day 1

10:30 Welcome + Workshop Information Introduction of participants, Expectations 11:00 BMI prognostic modelling – potential health gains in the elderly population of NRW Monika Mensing (LZG.NRW, D) 12:00 Modelling effects of nutrition improvements on health outcomes Stefan Lhachimi (Leibniz Institute for Prevention Research and Epidemiology, Bremen, D) 12:45 DYNAMO-HIA open questions (1) 13:15 LUNCH (snacks) 14:00 Using DYNAMO-HIA batch-mode to perform probabilistic sensitivity analysis: the example of modelling health impacts of dietary salt reduction Hendriek Boshuizen (RIVM, Bilthoven, NL) 15:00 The effect of traffic-related air pollution on respiratory diseases in the municipality of Copenhagen Henrik Brønnum-Hansen (University of Copenhagen, Dep. of Public Health, DK)

16:00 DYNAMO-HIA open questions (2) 17:30 End of day 1 19:00 Joint dinner in the City Centre of Bielefeld

Day 2

09:00 Welcome + summary of day 1 09:30 The impact of smoking interventions on Disability-Free Life Expectancy and Healthy Life Years in France Wilma Nusselder (Erasmus MC, NL) 11:00 The health impact of interventions on selected lifestyle risk factors in Copenhagen Henrik Brønnum-Hansen (University of Copenhagen, Dep. of Public Health, DK) 11:30 DYNAMO-HIA open questions (3), further perspectives

13:00 LUNCH (snacks) and departure

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OdileMekel,HeadoftheDivision"HealthDataandAssessments,HealthCareSystem",wel-comedtheworkshopparticipantsandgaveabriefoverviewaboutaimsandtasksoftheNRWCentreforHealth,aswellasthehistoryofHealthImpactQuantificationactivitiesoftheCen-tre.AsthecurrentpresidentoftheHIAsectionoftheEuropeanHealthAssociation(EUPHA),OdilechairsworkshopsattheannualEuropeanPublicHealthconferences,andisamemberoftheHIAnetworkofGermanspeakingcountries.Until2008,HealthImpactQuantificationattheNRWCentreforHealth(andpredecessorinstitutes)focussedonenvironmentalriskfac-tors,facilitatedsince2005byusingSummaryMeasuresofPopulationHealthasintheWHOEnvironmentalBurdenofDisease((E)BoD)approachasrelevantoutcomesofquantification.After2008,theBoDmethodologyisalsousedforHealthImpactAssessment(HIA)andthescopewasenlargedbytakingalsootherriskfactors,intermsofe.g.behaviouralfactorsintoaccount.

TheNRWCentreforHealthorganizedandhostedafirstscientificexpertworkshoponhealthimpactmodellinginMarch20101,followedbyasecondworkshopin20112.TooldevelopersandusersofHIQmodelsdiscussedexperiencesandchallengesduringtheseworkshops.Resultsandadditionalcomparativeworkispublishedintwopublications3,4.

Inthecourseofthiswork,theDYNAMO-HIAsoftwarewasidentifiedasatoolpotentiallyusefulforapplicationinNorthRhine-Westphalia.Thispubliclyavailablesoftwarecanbeused,amongothers,tomodelthehealthimpactsofriskfactorexposurevariationdynamically.ThetooliscurrentlyadoptedforNorthRhine-WestphaliabytheNRWCentreforHealth(section"Healthassessmentsandforecasting"),tosupportregionalHIAbyimpactquantification.

1 https://www.lzg.nrw.de/_media/pdf/liga-fokus/LIGA_Fokus_11.pdf2 https://www.lzg.nrw.de/service/veranstaltungen/archiv/2011/110413_workshop_health_impact_quantification/index.html3 FehrR,HurleyF,MekelOCL,MackenbachJP.Quantitativehealthimpactassessment:takingstockandmovingforward.J.Epidemiol.

CommunityHealth.2012Dec;66(12):1088-91(http://jech.bmj.com/content/66/12/1088.abstract)4 FehrR,MekelOCL,HurleyF,MackenbachJP.Healthimpactassessment:Asurveyonquantifyingtools.EnvironmentalImpactAssessment

Review.2016Feb;57:178-86(http://www.sciencedirect.com/science/article/pii/S0195925516000020)

Welcome TheNRWCentreforHealth:overviewofactivitiesrelatedtoHIAandHIQ

Odile Mekel NRWCentreforHealth(Germany)HeadofDivisionHealthDataandAssessments,HealthCareSystem

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ThefirstadoptionoftheDYNAMO-HIAtoolforthefederalstateofNorthRhine-Westpha-liafocussesontheriskfactorBMItoestimateaccordingpreventionpotentialsexpressedinhealthoutcomes,especiallyinthe60-80yearsagegroup.HighBMIisthesecondmostimportantriskfactor(afterdietaryrisks)inGermanywhenitcomestoBurdenofDisease:11%Disability-AdjustedLifeYears(DALY)areattributabletohighBMIin2010,contributingtocancer,cardioandcirculatorydiseases,Type2Diabetes(T2DM)(GlobalBurdenofDiseaseStudy2010)andmusculoskeletaldisorders.MonikaMensingpresenteddifferentsimulation

scenarios,includingreductionscenariosassumingthatbeha-viouraland/orenvironmentalpreventionmeasuresreachingadultpopulationinNRWwillsubstantiallylowertheprobabilityofbecomingoverweightoverthelifecourse.Inaddition,apes-simisticscenariowasdeveloped,representingthesituationthatthenegativetrendduringthelast2decades,theriseofover-weightprevalence,wouldcontinueinthenext20years.

ThelargesthealthimpactsinallscenarioscouldbeestimatedforType2Diabetes:inthepes-simisticscenario,wewouldexpectapprox.12,000excessT2DMcasesinthe60-80yearsoldin2035,comparedtothereferencescenariothatassumesnofuturemajorchangesinriskfactorexposure.Inthereductionscenarios,assumingastabledecreaseofprobabilitytochan-gefromnormalweighttooverweight(andfromoverweighttoobesity),upto34,000excessT2DMcasesareestimatedtobesaved,comparedtothereferencescenario.Potentialhealthgainsinischemicheartdiseasewereestimatedtobemuchlower–andrelevantimpactonstrokeorcancerscouldnotbeidentifiedforthesametimeperiod(2015–2035).

ModelledhealthgainsbymodifyingtheriskfactorBMIseemtobeconsiderablysmallercom-paredto,e.g.,smoking.Whatmostmodellingapproacheshaveincommon,regardlessoftheriskfactorinquestion,isthelackoflongitudinaldataoneffectsofpreventionmeasures.

BMI prognostic modelling PotentialhealthgainsintheelderlypopulationofNRW

Monika MensingNRWCentreforHealth(Germany)SectionHealthassessmentsandforecasting

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Modelling effects of nutrition improvements on health outcomes

Johanna-KatharinaSchönbachandStefanK.Lhachimipresentedaproposedoutlineformodellingpotentialeffectsofnutritionimprovementsontheriskfactor“obesity”andarangeofassociatedchronicdiseasesusingDYNAMO-HIAincooperationwithSilkeThiele(UniversityofKiel).TheunderlyingideaistoquantifytheimpactofintroducingahypotheticaltaxonfatinGermany,namelybytaxingproductsaccordingtotheiramountofsaturatedfattyacids(SFA).

Withthisapproach,theauthorswillsimulatea2004WHOrecommendationaboutusingfiscalpoliciestoinfluencefoodpricesandhenceencouragehealthiernutrition.

Previousmodellingstudieshaveshownpotentialeffectsoffoodtaxesandsubsidiesondietsandcorrespondinghealthoutcomes(e.g.bodyweight,chronicdiseases),bygivingfinancialincentivestoconsumers.

Theconceptexamines—viapriceelasticities—towhichextentfoodintake,itsassociatedcalo-rieconsumptionandthusBMIcouldbereduced.WithDYNAMO-HIA,thelong-termeffectsofthisassumedBMIreductiononmortality,lifeexpectancyandBMI-associatedchronicdiseaseswillbequantitativelymodelled.Theapproachaccountsforcross-priceelasticities.Inadditiontothat,itconsidersthatsocioeconomicstatusgroupsreactdifferentlytopriceincreases,the-rebyexploringvaryingefficiencyofafiscalpolicywithregardtohealthoutcomes.

Johanna-Katharina Schönbach BIPS/UniversityofBremen(Germany)

Stefan K. LhachimiBIPS/UniversityofBremen(Germany)

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PART A: FROM „FAT TAX“ TO CALORIE CONSUMPTION

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“Basket of goods” in reference

scenario (i.e. demand of food items

and food groups)

Demand/ consumption change for

different food groups

change in daily calorie consumption

tax on products/items according to

amount of saturated fat

Identifying amount of saturated

fat and calories for food items

using nutrient information

price increase for food items

according to amount of saturated fat

and consequentially price increase

for corresponding food groups

Elasticities

PART B: FROM CALORIE CONSUMPTION TO HEALTH OUTCOMES

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Modelling applying Dynamo

Health outcomes: life expectancy, IHD,

stroke, diabetes, COPD, lung-, breast-,

oral-, colorectal-, esophagal cancer

(by income levels)

BMI structure reference scenario (%

normal, overweight, obese)

BMI structure alternative scenario (%

normal, overweight, obese)

Weight reduction

change in daily calorie consumption

Health outcomes: life expectancy, IHD,

stroke, diabetes, COPD, lung-, breast-,

oral-, colorectal-, esophagal cancer

(by income levels)

RRs RRs

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WilmaNusselderledtheparticipantsthroughherscientificworkonmodellingtheHealthyLifeYears(HLY)indicator,oneoftheSummaryMeasuresofPopulationHealth,knownashealthexpectancies.OneoftheEU’stargetsistoincreaseHLYby2yearsuntil2020.Impactesti-matesviadynamicmodellingcanbeofhelpinthiscontext.Inprinciple,twoapproachesareconceivableinthiscontext:a)adisease-lessdirectapproach,notmodellingdiseases,buthazardsofmortalityanddisabilitythatresultinstantaneouslyfromtheriskfactor,andb)adisease-specificapproach,model-lingthesumsofrisksofmortalityanddisabilitywhethertheyhavetheirrootsin“background”all-causesorinDYNAMO-HIA-integrateddiseases.Asanexamplefora),Wilmamodelledthedirecteffectsofdifferentsmo-kinginterventionscenariosonall-causemortality(usingrelativerisks)anddisabilities(usingoddsratios),lookingattheoutcomesforHLYandlifeexpectancyfortoday15-year-oldsinFrance.Thebenefitofbetweenabout3(women)and5(men)HLYinafavourable,butunrealistic“smo-king-freepopulation”-scenarioadumbratesthelargelossesduetosmoking.Thescenario“nosmokinginitiation”requiresperseverance,sinceitssubstantialeffectstakealongtimeinthelife-coursetomanifest,whilescenario“allsmokersquit”resultsintomuchquickerbutsmal-lerestimatedgains.Reasonablereal-lifescenariostargetingsmokingcessationandinitiationseemtohaveonlysmalleffectsonHealthyLifeYearsintheshortterm.Asanexampleforb),theimpactsofphysicalactivity(PA)interventionsonDisability-FreeLifeExpectancy(DFLE)ofcohortaged50yrs.intheNetherlandsweremodelled.Datarequirementsareremarkable:

Modelling the effects of intervention and policies on Disability-FreeLifeExpectancyusingDYNAMO-HIA

Wilma NusselderErasmusUniversityMedicalCenterinRotterdam,TheNetherlands

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dataonriskfactorprevalenceinthepopulationanditssensibilitytointerventionmeasuresareneededandhavetobeimplementedinthesoftware.Furthermore,theassociationsbetweentheriskfactor,chronicdiseases,disabilityandmortalityhavetobederivedfromtheliteratureorassessedfromindividualdata.Themodellingrevealsthattheinvestigatedinterventions“Activeplus”(active-plus.nl)and“10,000StepsGhent”couldonlyreachbetween0.5and1yeargaininDFLEforthecohort,if100%ofthecohortwouldbereachedbytheseinterven-tions.Theoveralllifeexpectancywouldslightlybeprolonged.

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HenrikBrønnum-HansenintroducedanapplicationexampleofDYNAMO-HIAforthemunicipalityofCopenhagen,capitalcityofDenmark.Copenhagen,withapprox.580,000relativelyyoungciti-zens,ischaracterizedbyanabove-averagepopulationdynamic:youngpeoplemovingtothecityforeducationalreasonsandleavingagainwhenfoundingfamilies.Therefore,modellinginterventionsforCopenhagenalwaysbearstheriskthatthe“effectleavesthecity”,whilethosewhoimmigratewillonlybepartlyeffected.Astomodel-linghealthoutcomesofairpollution,measuringtheexposure,itsassociationswithdiseasesandthedynamicoftheexposeddemographymentionedabovearechallengingtasks.

HenrikuseddifferentlevelsofNO2(nitrogendioxide)concentrationasthebestavailableproxyoftraffic-relatedairpollution,increasingtheriskoflungcancerandchronicobstructivepul-monarydisease(COPD).Theexposurewasestimatedbyusingpubliclyavailabledataof99airqualitymeasuringstationsinCopenhagen.

Explorativemodellingresultsrevealedthat,ifitwaspossibletoreduceNO2-exposuretoalowlevelthroughoutthecity,anestimatedtotalofapprox.568lifeyearswithoutlungcan-cer(men)and3422lifeyearswithoutCOPD(men)couldbegaineduptotheyear2040.Forwomen:672years(lungcancer)and4092lifeyears(COPD),respectively.Limitationsoftheapproach,likedifficultiestomeasureexposuretoairpollutionduetovariationsinplaceandtimeandduetomigrationhavetobekeptinmind.Sincethepresentationattheworkshop,muchmoreeligibleexposuredatahasbeenprocured.Thus,thereportedresultsshouldbeconsideredasverypreliminary.

The effect of traffic-related air pollution on respiratory diseases inthemunicipalityofCopenhagen(DK)

Henrik Brønnum-HansenFacultyofHealthandMedicalSciences,UniversityofCopenhagen,Denmark

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Department of Public Health

High NO2 level Medium NO2 level Low NO2 level

Section of Social Medicine

Men WomenAge

Number of Copenhageners

Population pyramid, Copenhagen 2040 according to Statistics Denmark forecast

50

0

100

Statistics Denmark Statistics Denmark

Men WomenAge

Number of Copenhageners

Population pyramid, Copenhagen 2040 from DYNAMO-HIA and Statistics Denmark forecast

DYNAMO-HIA DYNAMO-HIA

50

0

100

Statistics Denmark Statistics Denmark

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HenrikBrønnum-Hansen’ssecondapplicationofdynamicmodellingismorebroad-basedanddedicatestophysicalinactivity,highalcoholconsumptionandsmokingandtheirimpactsonischemicheartdisease,stroke,lungcancerandCOPD.HenrikhasaccesstocomprehensivedatasourcesfromtheDanishnationalHealthSurvey,StatisticsDenmark,theDanishNationalPatientRegisterandtheDanishRegisterofCausesofDeath.

Thealternativescenariosofthe3modellings,incomparisontothebusiness-as-usualscena-rio,canbedescribedas“Nocitizenissedentaryinleisure-time”,“Nocitizendrinksmorethantherecommendedalcohollimit”and“4%smokingprevalenceinyear2025”.Thechallengeofestablishingreasonabletransitionprobabilitiesbetweensmokingcategorieswasdealtwith.Uptotheyear2040,womeninCopenhagenwouldgainespeciallybythecessationofsedentarybehaviour,prolongingtheirperiodlifeexpectancybymorethan2years.The(almost)smoke-freeCopenhagenaccountsfor1estimatedadditionalyear,drinkinglessforabout0.25years.FormeninCopenhagen,thesmoke-freescenarioisthemostbeneficialone,prolongingtheirlifeexpectancybyapprox.1.25years.Physicalactivityduringleisuretimeaddsanestimated1.1years,drinkinglessaddsapprox.0.2years.

The health impact of interventions on selected risk factors inthemunicipalityofCopenhagen(DK)

Henrik Brønnum-HansenFacultyofHealthandMedicalSciences,UniversityofCopenhagen,Denmark

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Section of Social Medicine

Data sources • Risk factor exposure

Danish National Health Survey

• Population demographics Statistics Denmark

• Incidence and prevalence of relevant diseases The Danish National Patient Register

• Mortality from relevant diseases and all-cause The Danish Register of Causes of Death

• Estimates of relative risks Epidemiological studies

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Whenmodellingpotentialfuturedevelopmentsquantitatively,performinguncertaintyorsensi-tivityanalysisisindispensabletoassesstherangeofeventsthatmightoccurandtoestimatetheaccuracyofmodellingresults.Changingoneormoreinputparameterenteringthemodel(univariate/multivariateuncertaintyanalysis)andinvestigatetheeffectsonoutputsresultsarepossibleapproachestodoso.HendriekC.Boshuizenpresentedathirdoption:thepro-pagationofuncertaintybyusingaMonteCarlosimulationapproach.Byrandomlyandrepea-tinglydrawingvaluesfromthedistributionoftheinputparametersandincludingthemtothemodel,hundredsorthousandsofoutputestimatesaregenerated,thusprovidingaconfidenceintervalfortheoutputofinterest.UsingDYNAMO-HIAintheso-calledbatchmodeallowsauto-maticrunningofthisvastnumberofsimulations.

Hendriek’sPhDstudentMariekeHendriksenappliedthetechniqueonthesimulationofred-ucedsaltintakeimpactonsystolicbloodpressureastheriskfactorandsubsequentlyonthehealthoutcomesofischemicheartdisease,strokeandmortality.Hendriekpresentedpro-jecteddiseaseprevalenceandmortalityreductionsover20yearsfornineEuropeancountriesduetoa30%saltintakereductionfromthisstudy.Theconclusiontobenoted:probabilisticuncertaintyanalysisisfeasible,butrequiresprogrammingskills.ThebatchmodeisalsoausefultoolforrepeatedcalculationsinDYNAMOapplicationfields,soit’sworththeefforttobecomefamiliarwiththetechnique.

Using DYNAMO-HIA batch-mode to perform probabilistic uncertain-ty analysis Theexampleofmodellinghealthimpactsofdietarysaltreduction

HendriekC.BoshuizenNationalInstituteforPublicHealthEnvironment(RIVM),Bilthoven,TheNetherlands

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Thepresentationsoftheworkshopparticipantsandthelivelydiscussionsdemonstratedimpo-singlythewiderangeofpossiblemodellingapplicationsoftheDYNAMO-HIAinstrument.

Bythegenericcharacterofthesoftware,allowingtheusertoaddfurtherriskfactors,healthoutcomes,andlocalprevalencedataforthegeographicalareaofinterestorupdatedexposu-re-response-functions,DYNAMO-HIAhasprovedvaluableindifferentscientificissues.

However,itmustbeacknowledgedthattheproperuseoftheinstrumentrequiresacertaintimefortrainingaswellasacomprehensiveepidemiologicalunderstanding.Thechallengeof‘translating’futureriskfactorexposurescenarios,assumptionsaboutbehaviouralchangesduetopreventivemeasures,andconsequencesforpopulationhealthintoworksheetstobeimportedinthesoftwareshouldnotbeunderestimated.Questionsarisinginthiscontextcane.g.bedescribedasfollows:

Whattodobestwhen(longitudinal)evidencedataisnotavailable?

HowtotranslateRelativeRisks(orOddsRatios)frommeta-analysesofinterventionstudies,ornationalHealthGoals,intocomprehensibletransitionratesfordifferentagegroups?

Whatpotentialpitfallsshouldbekeptinmind,whenaugmentingtheexistingDYNAMO-HIAdatabase?

HowtodealwithDALYsandthecorrespondingdisabilityweights?

Howtodofeasiblesensitivityanduncertaintyanalyses?

Howtoaddressmodellingresultstothepolicy-makingprocess?

RegularcommunicationandanexchangebetweenusersofDYNAMO-HIA,aswellasotherresearchersinvolvedinhealthimpactquantificationarefurtheronindispensablenecessarytoensurereliablemodellingresults.

Therefore,theworkshopparticipantsintendtoorganizefuturemeetingstomaintainthedialogandfacilitatecooperationalworkinthisfield.

Future perspectives

LandeszentrumGesundheitNordrhein-Westfalen

Gesundheitscampus-Süd944801BochumTelefon:023491535-0Telefax:[email protected]

dynamo-hia - international experiences, results & further ...dynamo-hia – international...

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