Abstract
Dear Editor,
We read with great interest the study by Zhao on global trends in the burden and quality of care for upper gastrointestinal (GI) diseases, from 1990 to 2021, based on the Global Burden of Disease Study 2021.[1] We commend the author for undertaking this comprehensive analysis of three major upper GI conditions—gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and gastritis/duodenitis (GD)—and for systematically evaluating the quality of care index (QCI) across regions, sexes, and age groups. The finding that age-standardized incidence and disability-adjusted life-year (DALY) rates for GERD showed an upward trend while those for PUD and GD declined substantially is particularly noteworthy and has clear implications for differentiated public health strategies.
However, certain methodological aspects warrant attention. The QCI, while a useful composite measure, is derived from population-level outcomes including the mortality-to-incidence ratio and DALYs-to-prevalence ratio. As the author acknowledges, the QCI does not directly capture process-of-care indicators such as endoscopic availability, guideline adherence, or Helicobacter pylori testing coverage.[2,3] Consequently, the notion of “quality” embodied by QCI may not be equivalent when comparing countries at vastly different stages of health system development. This limitation could be further explored in future work by integrating clinical process indicators where available.
Another consideration relates to the data source itself. GBD estimates rely on modeling approaches such as DisMod-MR 2.1 to impute missing data, particularly for low-sociodemographic index (SDI) regions where primary data may be sparse or of variable quality.[4] The marked QCI improvements observed in some low-SDI countries—such as Cambodia with an EAPC of 19.887—might partly reflect changes in data availability or modeling assumptions over time, rather than genuine improvements in care delivery alone.
The sex-specific finding that females maintained consistently higher QCI than males is thought-provoking. The author attributes this to women’s greater health awareness and healthcare-seeking behavior,[5] as well as higher rates of tobacco and alcohol use among males.[6,7] However, it would be valuable to explore whether differences in disease subtype distribution between sexes also contribute to this disparity, given the substantial heterogeneity in burden trends among GERD, PUD, and GD.
Finally, the cross-national inequality analysis demonstrated encouraging reductions in both absolute and relative inequality between 1990 and 2021. Yet it remains concerning that the QCI gap between the highest and lowest SDI regions persisted. Future studies could investigate whether targeted international collaborations, such as H. pylori screening programs and endoscopy training initiatives, have measurably accelerated QCI improvements in specific low-SDI settings.[8]
Despite these limitations, this study represents a valuable contribution to the growing body of evidence on the global epidemiology of upper GI diseases. The disaggregation of burden and quality-of-care trends by disease subtype provides crucial scientific evidence for developing differentiated intervention strategies. We applaud Dr. Zhao for this meaningful work.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
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