Abstract Background The burden of disease (BoD) methodology is a valuable tool for evidence-based policymaking. However, there is currently no systematic analysis available regarding its use in the European Union (EU) legislation framework. This study aims to describe the implementation of BoD methodology in EU legislation. Methods A search was conducted on EUR-Lex, the official and most comprehensive platform to access EU legal documents. The main inclusion criteria in the analyses were date of publication (between 2004 and 2023, accounting for EU-25) and inclusion of BoD metrics (years of life lost - YLL, years lived with disability - YLD or disability-adjusted life years - DALY). Descriptive and network analysis were conducted to analyse the legislation content. Results Out of 2592 documents, 191 met the set criteria. Ten were legally binding, and 69% were published after 2018. The European Commission (n = 152) was the most regular issuing institution. BoD was mainly used as an argument (n = 93) and for impact assessment (n = 50). The metrics were commonly presented in the main text (n = 122) and in the annex (n = 48). EuroVoc domains like environment and social questions prevailed. The most frequent EuroVoc terms were climate change policy (n = 45), EU environmental policy (n = 32) and pollution control measures (n = 32). Discussion Despite the growing recognition of BoD metrics in supporting policymaking, only 191 documents published over the past 20 years within the EU legislation make reference to this methodology. Greater efforts in knowledge dissemination and directing research towards specific policy uptake may increase the application of BoD studies in EU policies. By advocating for increased awareness, promoting collaboration between researchers and policymakers, and targeting research efforts towards specific policy needs, a more comprehensive integration of BoD methodologies into EU legislation can be achieved, contributing for evidence-informed policies. Key messages • There were only 191 documents of the EU legislative documents published in the past 20 years mention burden of disease metrics, mainly addressing environmental and social issues. • There is a need to increase EU policy uptake from BoD studies, by conducting policy-oriented research, and building capacity among researchers and policymakers on BoD methodology.

Abstract Background The shift of selected surgical procedures from inpatient to outpatient settings has been seen as a solution to improve health care provision. These shifts often occur under pay-for-performance schemes, pay-for-efficiency schemes, or other forms of financial incentives. For this study, we aimed to assess the effect of Decree 132/2009, implemented on February 1, 2009, which increased the relative weights of DRG 60 (“tonsillectomy and/or adenoidectomy, age <18”) performed in outpatient settings, thus acting as a financial incentive. Methods We performed a quasi-experimental study and employed interrupted time series (ITS) and controlled interrupted time series (CITS) designs, using monthly pediatric data provided by The Central Administration of the Health System (ACSS), with discharges between January 2006 and February 2012 (having 37 months pre- and post-decree implementation) of inpatient and outpatient episodes for DRG 60 (affected group) and DRG 163 (“hernia procedures age <18”, the selected control group). We used as study outcomes proportions (number of outpatient episodes divided by the sum of outpatient and inpatient episodes) to quantify increases in outpatient episodes and ratios (number of outpatient episodes divided by the number of inpatient episodes) to quantify decreases in inpatient episodes. Fourier terms were included to adjust for seasonality. Results We obtained statistically significant results only at the trend level for ratios when using the ITS model (0.01574) and for proportions only when using the CITS model (0.00310), although small non-statistically significant increases were obtained for the employed ITS as well as for the CITS design. Conclusions Decree 132/2009, which created financial incentives for the shift from inpatient to outpatient for DRG 60, showed low and non-statistically significant increases using both ITS and CITS models. Key messages • We analyzed the impact of Decree 132/2009 on the pediatric surgeries under DRG 60 performed in outpatient settings in Portugal using interrupted time series and control interrupted time series. • The decree had a small effect at the national level for DRG 60.

Abstract Background Health inequalities are an unjust and avoidable problem. This study examines subnational geographical inequalities in all-cause years of life lost (YLLs) and the association of socioeconomic factors in pre-coronavirus European Economic Area (EEA) countries. Methods In this ecological study complimented with a longitudinal analysis, demographic and socioeconomic data for 1390 small regions and 285 basic regions of 32 EEA countries were extracted from Eurostat. Age-standardised YLL rates per 100,000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease Study. Inequalities were assessed using the Gini coefficient (GC) and slope index of inequality (SII). The association between socioeconomic factors by YLLs were assessed using negative binomial mixed models in 2019. Findings Over the period 2009-2019, YLLs have decreased in almost all subnational regions. The GC of YLLs across EEA regions was 14% for females (95% CI = 13·5 to 14·6%) and 17% for males (CI = 16·1 to 17·5%). Greece (GC = 10·1%, CI = 7·8 to 2·5%) and Belgium (GC = 10·8%, CI = 9·5 to 12·0%) had the highest relative inequalities in YLLs for women and men, respectively. Subnational regions with the lowest income (incident rate ratio (IRR)=1·39, CI = 1·23 to 1·58) and levels of educational attainment (IRRfemales=1·19, CI = 1·13 to 1·26; IRRmales=1·22, CI = 1·16 to 1·28), and highest poverty risk (IRR=1·18, CI = 1·12 to 1·25) were associated with increased YLLs, with stronger associations observed in Central and Eastern Europe. Interpretation Differences in YLLs remain within and between EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing specific health inequities to improve overall disease burden within the EEA. Key messages • The study highlights the need for public health policies targeted at the subnational level to reduce health inequalities in the EEA. • The study describes the effect of existing public health policies targeting socioeconomic factors.

Abstract Background In addition to information on mortality and morbidity from diseases and injuries, it is important to identify the attributable burden of risk factors to allow for health planning and prioritization. Methods For the whole EU and each country, using estimates and 95% uncertainty intervals from the GBD 2019 study, we report attributable (all-cause and by level 2 risk factors) age-standardized death and DALY rates, as well as summary exposure values (SEV). We evaluate trends by comparing estimates for the year 2019 with those for the year 2010. Results Age-standardized death and DALY rates attributable to risk factors declined by 10.7% (95%UI 13.8%-7.6%) and 9.1% (95%UI 12.0%-6.3%), between 2010 and 2019 in the EU. While there was a decreasing trend for both age-standardized death and DALY rates for almost all risk factors, some showed an increasing trend on SEV, including low physical activity and intimate partner violence. Conclusions Despite the improvement of health metrics attributable to risk factors, several modifiable behavioral and metabolic risk factors remain unchanged over the years. It is crucial to ensure a swift implementation of evidence-based policies and interventions in EU member states to achieve the targets of the Sustainable Development Goals.

Abstract Background Non-communicable diseases (NCDs) remain the leading cause of disease burden in the European Union (EU). However, this burden varies across Member States, driven by the socioeconomic and demographic structure of the populations, as well as health care and social support systems in each country. This geographical gradient in the burden of NCDs represents health inequalities that may have expanded as a result of population ageing, migration, and economic crisis, and historic backgrounds. Methods Using data from the GBD 2019 study, we quantify the inequality gap between EU countries, characterize the geographical gradient of total and individual NCDs, and analyze the trends over the last 20 years. Results A considerable gap exists in the rates of NCD-related DALYs between the country with the lowest burden (Slovenia in 2019) and the highest (Bulgaria in 2019), with a constant (p-trend > 0.05) ratio of 1.6 (95%CI, 1.57; 1.64) since the year 2000. The largest inequality was observed for the burden of stroke between the lowest (France in 2019) and the highest (Bulgaria in 2019) with a ratio of 7.47 (6.78; 8.24) Increasing steadily (p-trend < 0.001) since 2000. Using the relative index of inequality to characterize the gradient of inequalities across the EU, a decreasing trend (p < 0.001) can be observed for NCD-related DALYs rates from 1.56 (1.44; 1.7) in 2000 to in 1.42 (1.33; 1.52) 2019. Conclusions Despite overall improvements in health, spatial disparities related to NCDs in the EU persist. Our estimates provide a baseline to inform future equitable health policies.

Abstract Background The European Union (EU) faces many health-related challenges. Accurate and timely data on mortality and morbidity from diseases and injuries and their trends over time are essential for health planning and priority setting. Methods We use the GBD 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardized death, YLL, YLD and DALY rates for Level 2 causes. We evaluate trends by comparing estimates for the year 2019 with those for the year 2010. Results In 2019, the age-standardized death and DALY rates in the EU were 465.8 and 20 251.0 per 100 000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases for age-standardized, death and YLL rates across EU countries. However, YLD rates remained mainly unchanged, with increases in the Netherlands and the ‘. The largest decreases in age-standardized DALY rates were observed for HIV/AIDS and sexually transmitted diseases and transport injuries (both -19%). On the other hand, only diabetes and kidney diseases showed a significant increase for age-standardized DALY rates in the EU (3.5%). Mental disorders showed an increasing age-standardized YLD rate, as well. Conclusions Overall, there was a visible trend of improvement in the health status in the EU with substantial differences between countries. EU health policy makers need to tackle incidence of diseases and injuries, with specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.