Physical Rehabilitation Needs per Condition Type:
Results from the Global Burden of Disease study 2017This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Archives of Physical Medicine and Rehabilitation 2020 (Feb 5) [Epub] ~ FULL TEXT
Tiago S. Jesus (Ph.D), Michel D. Landry (Ph.D), Dina Brooks (Ph.D), Helen Hoenig (MD, MPH)
Global Health and Tropical Medicine &
WHO Collaborating Center on Health Workforce Policy and Planning,
Institute of Hygiene and Tropical Medicine-NOVA University of Lisbon.
OBJECTIVE: To determine how total physical rehabilitation needs have been distributed per relevant condition groups (musculoskeletal & pain, neurological cardiothoracic, neoplasms, pediatric, and HIV-related), globally and across countries of varying income level.
DESIGN: Sub-group, secondary analyses of data from the Global Burden of Disease 2017. Data for the year 2017 are used for determining current needs, and data from every year between 1990 and 2017 for determining changing trends.
SETTINGS: Globally and High, Upper Middle, Lower Middle, and Low-Income countries.
PARTICIPANTS: Not applicable INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURE: Years Lived with Disability per 100,000 people (YLD Rates) for the 6 condition groups.
RESULTS: In 2017, musculoskeletal & pain conditions accounted for 52.6% of the total physical rehabilitation needs worldwide; HIV-related for 5.7% of the physical rehabilitation needs in low-income nations, but about 1% in all other locations. Worldwide, significant increases in YLD Rates were observed since 1990 for the 6 condition groups (p<0.01). However, across country types, we observed significant decreases in YLD Rates for specific conditions: pediatric in high-income countries, and neurological and neoplasm conditions in low-income (p<0.01). In upper middle-income countries, YLD Rates from neurological and neoplasm conditions grew exponentially since 1990, with overall increases of 67% and 130%, respectively.
CONCLUSION: At a global scale, physical rehabilitation needs per-capita are growing for all major condition groups, with musculoskeletal & pain conditions currently accounting for over half of those needs. Countries of varying income level have different typologies and evolutionary trends in their rehabilitation needs.
KEYWORDS: disability; global burden of disease; global health; health services needs and demand; rehabilitation
List of Abbreviations:
99% CI ( 99% confidence interval),
GBD ( Global Burden of Disease),
HIC ( high-income country),
HIV ( human immunodeficiency virus),
LIC ( low-income country),
LMIC ( lower-middle-income country),
UMIC ( upper-middle-income country),
YLD ( years lived with disability)
From the FULL TEXT Article:
Introduction
Worldwide, gains in health have dramatically increased life expectancy and reduced mortality. [1, 2] However, advances in health care have been far less dramatic in averting nonfatal health losses; indeed, many life-saving interventions result in life-long disabilities. [3] As a result, there is a growing focus on health policies and interventions that result in both longer and healthier lives.4 One way to do so is by strengthening the health systems’ capacity to provide rehabilitation services. [4-11]
Physical rehabilitation has the potential to improve health outcomes worldwide. [10, 12, 13] Rehabilitation has been shown to be a cost-effective health care intervention that enables people with physical impairments (e.g., in mobility) or symptoms (e.g., low back pain) to (re)gain or maintain personal independence and participate in broader aspects of daily life such as education, work, and social roles (e.g., parent). [4, 14-16] Physical rehabilitation can also result in reduction of secondary consequences of disability (e.g., deconditioning, pressure sores). Finally, rehabilitation can reduce overall costs of care through reduced hospital lengths-of-stay, preventing rehospitalizations, and enabling patients to be cared for at home. [14-17]
Despite its health and economic benefits, unmet physical rehabilitation needs are widespread. [11, 18, 19] Especially in many low- and middle-income countries, availability of physical rehabilitation resources is often a small fraction of what is needed (e.g. professionals estimated to be one-tenth of those required [14]), unevenly distributed within and across nations or service types, [20] and of suboptimal quality. [20-22]
Moreover, needs for physical rehabilitation have been growing worldwide. A recent study, using data from the Global Burden of Disease 2017, found a 66% increase since 1990 in the world’s Years Lived with Disability (YLD Counts), and 17% increase when adjusting for the growth of the population (YLD Rates).10 The same study also found that YLD Counts appropriate for physical rehabilitation more than doubled since 1990 in countries of low income (112% increase), while YLD Rates increased the most (by 30%) in upper-middle income nations.
In response to the widespread and growing unmet needs for physical rehabilitation, the World Health Organization launched the “Rehabilitation 2030” initiative. This initiative brings together key stakeholders to develop strategies and action plans to scale-up and improve the quality of rehabilitation services worldwide, [14] with a goal of reducing unmet needs for physical rehabilitation services. [13, 14] Hence, there is an acute need for data on the physical rehabilitation needs worldwide, to inform the planning of physical rehabilitation services and resources. However, it is not known yet which conditions are driving the physical rehabilitation needs, and how those may differ, in actual values or proportion, by country type, i.e. by the economic level of the country.
This study aims were to explore the typology, and the changing typology, of physical rehabilitation needs. Specifically, we describe how physical rehabilitation needs are distributed (in 2017), and have been distributed (since 1990), per relevant groups of conditions (i.e. musculoskeletal & pain, neurological cardiothoracic, neoplasms, pediatric, and HIV-related). That includes quantifying the yearly changes in physical rehabilitation needs (and in the portion of physical rehabilitation needs) arising for each condition group, globally and across countries of varying income level.
Methods
Design:
For this study, we used data from the Global Burden of Disease (GBD) 2017, [3] 90 the largest global epidemiological study to date, carrying out sub-group analyses of a previous study using that database. [10] In the previous analsyis, [10] we determined the changing trends, from 1990 to 2017, of the total physical rehabilitation needs (i.e. for all conditions combined), worldwide and across the groups of high-income countries (HICs), upper middle-income countries (U-MICs), lower middle-income countries (L-MICs), and low-income countries (LICs). In this analysis, we stratify that data by relevant conditions groupings, both worldwide and according to country type (i.e., HICs, U-MICs, L-MICs and LICs).
Underlying health conditions and their grouping:
The underlying conditions deemed to benefit from physical rehabilitation were determined in the original paper [10] through a structured process. Briefly, the process started with search of systematic reviews on the effect of physical rehabilitation interventions for target health conditions. For conditions in which the evidence of physical rehabilitation benefit was not the sequalae, an explicit trade-off reasoning was applied to the selection decisions to include conditions and not others, with a goal to avoid either an under- or over-estimation of the total physical rehabilitation needs. The final set of health conditions deemed relevant to physical rehabilitation is presented in table 1, left column. Then, for this analysis, these conditions were aggregated into condition groupings, according to typical areas of physical rehabilitation practice: [23-25] musculoskeletal & pain; neurological, cardiothoracic, neoplasms, pediatric, and HIV-related (see table 1, right coluumn).
We also carried out a separate, further stratified analysis for 3 large groups of conditions (i.e. musculoskeletal & pain; neurological; and cardiothoracic conditions) to examine specific conditions. For example, in that analysis, data on cardiothoracic conditions are further broken down into that for cardiac and pulmonary ones. The condition grouping used for that stratified analysis is depicted in the table 1, middle column. Importantly, any these condition groupings and subsequent units of analysis were defined a priori of the data extraction.
Measures:
Physical rehabilitation needs were estimated through YLDs, which is the measure in the GBD study that focuses exclusively on non-fatal health losses. [3, 10] YLDs consist of the years lived with any short-term or long-term health loss weighted for severity by disability 126 weights. For stroke, for example, disability weights vary from 0.019 for mild consequences to 0.588 for severe consequences plus cognition problems. Details on how YLDs and disability weights are determined, and all the disability weight values, are available elsewhere. [3, 26] Here, envisioning the feasibility of the analysis, we used a single YLD metric, notably YLDs per 100,000 people (i.e. YLDs Rates), which adjusts YLD values to population size. This metric most directly informs the planning of physical rehabilitation resources, in terms of the population-adjusted amount of physical rehabilitation services and workforce required.
Income level:
We used the World’s Bank classification for HICs, U-MICs, L-MICs, and LICs.
Time span:
Data for the year 2017 were used to determine current physical rehabilitation needs per condition groupings, while data from every year from 1990 to 2017 were used for determining the change in rehabilitation needs. The use of multiple data points as a time series allowed us to more accurately detect the changing trend in rehabilitation needs.
Data Management & Analysis:
The YLD Rates for each health condition, extracted for the previous study, [10] were grouped according to the structure in table 1. Those YLD Rates can also be extracted from the original source, the GBD 2017, through the freely - available platform (http://ghdx.healthdata.org/gbd-results-tool).
The Microsoft’s Excel software, [a] with the XLMiner Analytical ToolPak, was used for data storage, management, and analysis. Within each location, yearly YLD Rates were summed up for each condition group. Also, we computed relative percentages for each of those values and we used the YLD Rates for the total physical rehabilitation need (i.e. all conditions germane to physical rehabilitation combined) [10] as common denominator. That percent value allowed us to determine which, for any given year, was the portion of the total physical rehabilitation needs that came specifically from each condition group.
Then, yearly values were plotted and analyzed for each location using regression models. That included determining whether the data fitted better into a linear, exponential or logarithmic regression model, as determined by both visualization and r2 values of the alternative models. Whenever differences between r2 values were minimal (i.e. <0.02), the linear option was retained. The Web-Appendix 1 provides all the graphs and visually depicts the respective regression models that best fit the data.
Linear regression analyses, with the use of ANOVA, were used to determine any significant yearly changes in YLDs Rates and their relative percentage per condition group from 1990 to 2017. In each of those regressions (i.e. one per country type, within each condition group), we used respective YLD Rates as the dependent variable and the years as the independent variable. The same analytical approach was employed also for the data that best fit into an exponential or logarithmic regression model. In those cases, we used both the actual YLD Rates or a log-transformed version of these.
In no case for any of the six major groups of conditions did it make a difference in the significance level of the findings. Hence, although and confidence intervals for the actual YLD Rates (not the log-transformed ones), so to report the magnitude of the yearly change estimates in actual YLD Rates. Nonetheless, we still signal that such data had a best fit into a logarithmic or exponential model type (e.g. growth rate higher in the earlier or later years, respectively), which informs on the temporal trend. Finally, within the ancillary analyses (i.e. sub-stratifying data on type of cardiothoracic conditions, etc, whose results are provided into appendixes), only in two cases did the analyses with log-transformed values provide a different significant level.
In those cases, we explictly report the statistical significance for the two approaches. Altogether, we consider two subsequent levels of statistical significance: P values <0.05 and p values <0.01. The latter reflects a Bonferroni correction that accounts for the five tests (i.e. one per location; 0.05/5 = 0.01) that were conducted per condition group / unit of analysis.
RESULTS
1- YLD Rates per condition groups
Table 2 shows that worldwide YLD Rates (i.e. YLDs per 100,000 people) relevant to physical rehabilitation have increased significantly from 1990 to 2017 for each of the six condition groups (p <0.01).
By stratifying the data per countries of varying income level, the following patterns were observed:
Table 2 shows that HICs and U-MICs had high increases in the YLD Rates for musculoskeletal & pain, neurological, and neoplasm conditions. For example, in HICs musculoskeletal & pain conditions accounted for 16.8 additional YLDs per 10,000 inhabitants a year (99% Confidence Interval (CI): 15.9 – 17.7) and U-MICs 20.5 (99% CI: 19.0 – 21.9).
Besides, in U-MICs YLD Rates from neurological and neoplasm conditions grew exponentially (both r2 = 0.95; p<0.01), i.e. at a higher rate in the more recent years, with overall increases of 67% and 130%, respectively (see Table 2), even though significant decreases in YLD Rates from the infectious type of neurological conditions were observed across country types (all p <0.01; see Web-Appendix 2).
Still in countries of higher income (i.e. HIC and H-UMICs), YLD Rates from cardiothoracic conditions grew substantially in HICs (b= 7.0: 99% CI: 6.3 – 7.7), and to a lesser degree in UMICs (b= 4.3: 99% CI: 2.2 – 6.4) (Table 2), while the Web-Appendix 2 shows that increases occurred predominantly in the YLD Rates for cardiac conditions in U-MICs (b= 3.3: 99% CI: 3.1 – 3.5) and for pulmonary conditions in HICs (b= 5.5: 99% CI: 4.8 – 6.2).
In turn, in countries of lower income (i.e. L-MICs and LICs), the growth of YLD Rates from pediatric conditions stood out. Indeed, we observed a significant increase of 4.6 YLDs a year per 100,000 inhabitants in L-MICs (99% CI: 4.4 – 4.8), and of6.4 in LICs ((99% CI: 5.8 – 6.9).
Despite overall global increases in YLDs Rates for conditions benefitting from rehabilitation, there were some scenarios where decreases in YLD Rates were observed. HICs had a 0.3 – (-0.1)), and LICs a decrease for YLD Rates coming from both neoplasms (b= -0.1: 99% CI: -0.2 – (-0.1)) and neurological conditions (b= -0.5: 99% CI: -0.7 – (-0.3)). The decrease in YLD Rates from neurological conditions in LICs was mostly driven by a reduction in the infectious type of neurological conditions (b= -0.6: 99% CI: -0.7 – (-0.5)) - see Web-Appendix 2 where table 2’s data are further stratified.
2- Percentage of physical rehabilitation needs
Table 3 shows that, in 2017, musculoskeletal & pain conditions account for over half of the world’s physical rehabilitation needs (52.6%); most of these came from pain conditions in particular (55.8%; 29.4% of the total). Moreover, we observe that musculoskeletal & pain conditions account for 57.7% of the physical rehabilitation needs in HICs but only 47.5% in LICs.
Cardiothoracic, pediatric, and neurological conditions also account for important portions of the world’s physical rehabilitation needs: 18.0%, 13.1%, and 12.9, respectively. Neoplasms, in turn, represent for 2.2% of the world’s physical rehabilitation needs, but nearly twice as much in HICs (4.1%). Finally, HIV-related conditions account for 1.2% of the physical rehabilitation needs worldwide, albeit accounting for 5.7% of the physical rehabilitation needs in LICs.
With respect to change between 1990 and 2017, table 3 shows that the portion of physical rehabilitation needs arising from musculoskeletal & pain conditions significantly decreased across countries of all income levels (all p<0.01). In turn, the portion of physical rehabilitation needs arising from neurological conditions and neoplasms significantly increased across country types, except for LICs in which a significant decreased was observed (all p<0.01). Table 3 also shows that in LICs the portion of physical rehabilitation needs coming from pediatric conditions was the only with a significant increase (p<0.01), and by an aggregate 30.6% from 1990 to 2017.
Finally, among neurological conditions, HICs and U-MICs saw a 21.3% and 41.6% increase respectively in the portion of physical rehabilitation needs coming from the non communicable type of neurological disorders, relative to the 0.9% and 8.0% increase respectively in LICs and L-MICs (see Web-appendix 3).
Discussion
This paper provides an exploratory analysis of the trends in distribution of physical rehabilitation needs per condition type, globally and across countries of varying income level. Several findings are particularly noteworthy.
First, substantial growth of YLDs per capita occurred worldwide in all condition groups benefitting from physical rehabilitation. Likely this is a reflection of the growing prevalence worldwide of chronic, non-communicable and disabling health conditions, [3, 7, 27] due to factors such as:1) increased life expectancy and population ageing; [7, 28, 29]
2) increased medical advances and survival rates for those with heretofore fatal conditions but which often leave sequalae benefitting from physical rehabilitation (e.g. neoplasms, HIV, stroke); [30, 31] and
3) increased rates of obesity and sedentary lifestyles [32, 33] that lead to higher risks for musculoskeletal, cardiovascular and other conditions with sequalae responsive to physical rehabilitation.The reduction of physical rehabilitation needs from infectious related neurological conditions, partly due to increased vaccination rates and improved health care, did not offset the overall increase in physical rehabilitation needs coming from non-infectious neurological conditions.
Second, we observed important differences in the typology and growth of physical rehabilitation need according to the countries’ income level. For instance, L-MICs and LICs had both a higher portion and growth of physical rehabilitation needs coming from pediatric conditions. Likely, this finding is due their population’s age structure, from higher fertility rates and lower life expectancy, [1, 2, 34] in combination with reduction in neonatal and children’s mortality [1, 35] and increasing survival rates and life expectancy for those with developmental disabilities. [36, 37]
We also found that LICs had 6% of their physical rehabilitation needs attributable to HIV-related conditions, while for the other countries this estimate was equal to, or less than, 1%. While this difference in HIV-related conditions may reflect a higher prevalence of HIV in LICs, [38] it may also reflect increasing access to anti-retroviral therapy in LICs, which increasingly transforms this life-threatening condition into a chronic, disabling condition. [30] Thus, based on our results, improving survival of children and services to enable optimal health outcomes.
Third, in U-MICs, physical rehabilitation needs arising from neoplasms and neurological conditions have grown exponentially, despite the significant decrease in the infectious-type of neurological conditions. Also, the growth of physical rehabilitation needs from cardiac conditions stood out in U-MICs. Potential contributing factors include economic development with changes in diet and more sedentary life style increasing the prevalence of health conditions with adverse cardiovascular and neurological sequelae (e.g., hypertension, hyperlipidemia), neurological trauma related to higher use of motor vehicles, and increased life expectancy from the advances in health care. [32, 33, 39] The observed levels and typology of physical rehabilitation needs of U-MICs were approaching those of wealthier nations.
Fourth, in HICs, we found that musculoskeletal and pain conditions account for a higher portion of physical rehabilitation needs than in any other country type, while physical rehabilitation needs coming from neoplasms and pulmonary conditions had the greatest increase over time in YLD Rates. Potential contributory factors include higher life expectancy and related population ageing in HICs, advances in cancer care, historical smoking patterns and environmental pollution. [2, 28, 31, 40]
Finally, using YLD Rates as a metric, we found that musculoskeletal and pain conditions account for over than 50% of the world’s physical rehabilitation needs, even though a significant decrease in that percent value was observed across country types. This high portion might be due the higher prevalence of musculoskeletal and pain conditions, [3, 27] even though many sequelae of neurologic conditions (e.g. stroke with severe consequences plus cognition problems) have higher disability weights [21] and may in turn consume more rehabilitation resources. That may be why other studies have found that neurological conditions had the highest volume of physical rehabilitation research. [23, 24] Another possible explanation is that we found a significant growth of the portion of physical rehabilitation needs coming from neurological conditions in all country types, except LICs. Prioritization for rehabilitation resource allocation and research is complex, and our analysis did not take into account rehabilitation intensity or resource allocation across the different condition categories.
Yet, combined with other types of data (e.g. methodological and knowledge gaps, perspectives from the minorities and the underserved), [41-44] metrics on physical rehabilitation needs can and should help inform global physical rehabilitation research priorities, as increasingly observed in other health fields. [45-51] For instance, these results can help inform research agendas on comparative effectiveness, health services and implementation research, to help identify high-value, cost-effective and locally-relevant rehabilitation solutions for conditions that have shown particularly important portions and/or increases in physical rehabilitation needs. Examples might include HIV-related and pediatric rehabilitation needs in LICs, pulmonary conditions in HICs, neurological conditions in U-MICs, and musculoskeletal and pain conditions worldwide. In other words, our data help highlight specific areas and conditions which, if targeted specifically, might generate highest value for improved health outcomes at the population level.
Study Limitations:
This study has the following limitations.
First, YLD Rates from selected health conditions is only a proxy indicator of physical rehabilitation need. YLDs for specific conditions account for the prevalence of that condition, the time during which sequalae are present, and the severity of those sequalae; however, it does not measure resultant functional limitations - a more proximate indicator of physical rehabilitation need.
Second, YLD Rates extracted from the GBD 2017 are only estimates modelled from the best available data and research, not actual YLD Rates. The quantity and quality of the data to produce those estimates vary by timing and location (e.g. typically lower in earlier times and LICs), which leads to varying levels of preciseness. That does affect the capacity to more precisely detect any significant change in the real YLD Rates based in the YLD Rate estimates the GBD study provides. It does not imply, however, systematic error toward under or over estimation of physical rehabilitation needs. At each new cycle, the GBD study apply newly collected data and more advanced estimation methods to re-calculate YLDs across locations and the entire time series.
Third, the selection of health conditions germane to physical rehabilitation followed an a priori methodology informed by existing systematic reviews, [10] but it cannot be considered as a fixed standard of conditions germane to physical rehabilitation as the field of rehabilitation is not static. The conditions appropriate for rehabilitation will continue to evolve with continued advances in rehabilitation therapies and research.
Fourth, the condition groups were established according to impairment types commonly treated by rehabilitation and/or benefitting from rehabilitation. However, the groupings do not depict where those conditions might best be treated (e.g., inpatient, outpatient) nor the timing of treatment (e.g., acute, episodic, chronic).
Fifth, unlike the preceding analysis of total physical rehabilitation needs which used 4 alternative YLD metrics, [10] we used only one YLD metric (i.e. YLDs Rates, i.e. YLDs per 100,000 population), and not Age-Standardized YLD Rates, for example.
Sixth, this study was exploratory in nature, looking for patterns in data from a large data set, rather than testing specific hypothesis generated a priori.
Seventh, we consider statistical significance with a minimum p values <0.01. Given the various linear regression analyses conducted, there is the possibility of a type I error.
Finally, the YLDs from one condition were all allocated to one impairment type, which is reductionist. For example, a few of the HIV-related impairments can be of a cardiothoracic type; leprosy can provide more than musculoskeletal sequalae, etc.
Conclusion
According to data from the GBD 2017, world’s physical rehabilitation needs per-capita are growing for all major groups of conditions germane to physical rehabilitation, with musculoskeletal & pain conditions currently accounting for over half of those needs. Countries of varying income level have different typologies and evolutionary trends in their rehabilitation needs. This paper shows that estimates from the GBD study can be used to identify the current typology of physical rehabilitation need and their changing trends over time. This type of estimates can be one indicator for an informed planning of the physical rehabilitation resources, services, and research to meet the expanding country-specific and global needs for rehabilitation.
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