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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
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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9 DYNAMO-HIA – International experiences, results & further perspectives
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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DYNAMO-HIA – International experiences, results & further perspectives
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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DYNAMO-HIA – International experiences, results & further perspectives
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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DYNAMO-HIA – International experiences, results & further perspectives
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]