The Economics of Prevention AHIA conference Sydney, 9 November 2010 - PowerPoint PPT Presentation

The Economics of Prevention AHIA conference Sydney, 9 November 2010 Prof Theo Vos Centre for Burden of Disease and Cost-Effectiveness School of Population Health University of Queensland For ACE-Prevention Research Team

Overview of the Session 1. Introduction to ACE-Prevention study 2. Results a) Individual interventions b) Intervention pathways c) Big picture ~ key messages; costs; cost savings; health gains from recommended packages 2

Brief History  ACE-Prevention was a 5 year NHMRC Health Services Research Grant (2005-2009)  Across 2 sites (UQ and Deakin)  Followed on from earlier ACE studies funded by both government & competitive grants  Largest study of its kind in the world  150 interventions assessed 3

Topic areas and interventions Total population Indigenous Topic Prevention Treatment Prevention Treatment Alcohol 9 2 Tobacco 8 Physical activity 6 Nutrition 26 Body mass 9 Blood pressure/cholesterol 12 5 Bone mineral density 3 Illicit drugs 2 1 Cancer 9 1 Diabetes 7 7 Renal disease 2 2 4 2 Mental disorders 11 10 Cardiovascular disease 1 5 Other 18 6 3 Total 123 27 19 2 4

Quick overview of economic methods Clear criteria for selection of interventions  Standardised evaluation methods to minimise  methodological confounding Evaluation conducted as integral part of exercise  (not collation from literature) ‘ Evidence ’-based approach with extensive  uncertainty & sensitivity testing Careful thought given to government policy  objectives and concept of ‘benefit’ 5

Economic protocol Perspective Health Sector (focus on government; key societal effects flagged) Comparator Current practice + no interventions (‘null’) for analyses of intervention mix Target pop Cohort of patients with conditions/risk factor of interest, Aust. population 2003 Time horizon Track costs & benefits 100 yrs or death Discounting 3% Costs Best available unit costs (documented); Real costs $AUD 2003 6

C/E analysis protocol (Pamphlet C) Cost per DALY saved + 2 nd stage filters Outcomes Uncertainty analysis 95% uncertainty intervals using probabilistic analysis Sensitivity analysis Test scenarios around key design features Reporting ICER point estimates & ranges; league tables cost-effectiveness planes; topic area expansion path; packages of interventions; 2 nd stage filters & implications 7

From policy to measurement of benefit  Two-stage approach adopted in ACE  First, a measure of health gain in relation to resources consumed ( $ cost per DALY )  Picks up element of cost, efficacy/effectiveness and efficiency objectives  Second, explicitly provide for broader considerations not in this C/E ratio  Which we call our ‘2 nd stage filters’ (equity; acceptability; feasibility; size of the problem)  Plus confidence in evidence base 8

Results 9

League table 10

DALYs, costs & cost-effectiveness ratios for alcohol interventions Intervention DALYs cost Cost offsets Net cost ICER averted $M $M $M $/DALY Taxation increase 30% 100,000 0.6 -530 -530 Dominant Volumetric taxation 11,000 0.6 -57 -56 Dominant Advertising bans 7,800 20 -31 -12 Dominant Minimum drinking age 21 150 0.6 -0.8 -0.2 Dominant Licensing controls 2,700 20 -11 9 3,300 Brief intervention 160 2.3 -1.2 1.1 6,800 Brief intervention + telemarketing 340 6.1 -2.6 3.5 10,000 Random breath testing 2,300 71 -17 54 24,000 Drink drive mass media 1,500 39 -11 28 14,000 Residential treatment & naltrexone 480 59 4.4 55 120,000 Residential treatment 190 37 -1.7 35 150,000 Cobiac L, Vos T, Doran C, Wallace A (2009).Cost-effectiveness of interventions to prevent alcohol-related disease and injury in Australia. Addiction, 104:1646-55 11

Results: cost-effectiveness plane $50,000/DALY threshold Volumetric 12

Summary ~ Triage Categories Dominant interventions Excellent < $10,000/DALY Very Good $10,000 - $50,000/DALY Good >$50,000/DALY Not C/E Key to results Health impact DALYs ++ +++ + (lifetime) Large Small Medium >100,000 0–10,000 10,000–100,000 $million Intervention cost ++ +++ + Large Small Medium (annual) >100 <10 10–100 13

Dominant interventions Excellent value-for-money Gain health and save costs Need very good reason to reject 14

Lifetime Annual health intervention Topic area Intervention impact cost Alcohol Volumetric tax ++ + Tax increase 30% +++ + Advertising bans + + Minimum legal drinking age to 21 + + Tobacco Tax increase 30% +++ + Physical activity Pedometers ++ ++ Mass media ++ ++ Fruit & veg Community fruit & veg promotion + ++ Salt Voluntary salt limits + + Mandatory salt limits +++ + Body mass 10% tax on unhealthy food +++ + BP&Chol Community Heart Health Program ++ + Polypill $200 >5% CVD risk +++ +++

Lifetime Annual health intervention Topic area Intervention impact cost Osteoporosis Screen women 70+ & alendronate ++ ++ Hepatitis B HBV vaccine + immunoglobulin to + + infants born to carrier or high risk mothers Selective HBV vaccination of infants + + with mothers from highly endemic countries Kidney disease Proteinuria screen & ACE-inhibitor ++ + for diabetics Mental disorders Problem solving post-suicide + + attempt Treatment for individuals at ultra- + + high risk for psychosis Oral health Fluoridation drinking water non- + + remote areas

Interventions < $10,000/DALY Very good buys 17

Lifetime Annual health intervention Topic area Intervention impact cost Alcohol Brief alcohol intervention GP ± + + telemarketing and support Licensing controls + + Tobacco Cessation aid: varenicline ++ +++ Cessation aid: bupropion ++ +++ Cessation aid: NRT ++ ++ Physical activity GP prescription + +++ Internet intervention + ++ Fruit & veg Information mail-out, multiple re- + + tailored Body mass Gastric banding +++ +++

Lifetime Annual health intervention Topic area Intervention impact cost BP & chol Low dose diuretics >5% CVD risk +++ +++ Polypill $200 to over 55s +++ +++ Calcium channel blockers >10% CVD risk ++ ++ ACE-inhibitors >15% CVD risk + ++ Mental Screen & bibliotherapy minor + ++ disorders, depression adults drugs, suicide Screening and psychologist to prevent + ++ childhood/adolescent depression Screening and bibliotherapy to prevent + + childhood/adolescent depression Responsible media reporting on suicide + + Parenting intervention for prevention + + of childhood anxiety disorders Other Universal infant HBV vaccination + ++

Interventions $10,000 - $50,000/DALY Good buys 20

Lifetime Annual health intervention Topic area Intervention impact cost Alcohol Drink drive mass media + ++ Roadside breath testing + ++ Physical activity TravelSmart + +++ GP referral + +++ Nutrition Multiple tailored mailed fruit & + + vegetable promotion Obesity Diet & exercise for overweight + +++ Low-fat diet for overweight + ++ BP & Chol Dietary counselling >5% CVD risk by ++ ++ dietitian Phytosterol >5% CVD risk ++ +++ Statins >5% CVD risk +++ +++ Statins + Ezitimibe >5% CVD risk +++ +++ ++ +++ Beta blockers >5% CVD risk +++ +++ CCBs >5% CVD risk +++ +++ ACE inhibitors >5% CVD risk

Lifetime Annual health intervention Topic area Intervention impact cost + ++ Cancer Pap screen (current practice) + + HPV DNA test screening 3-yearly from 18 HPV vaccination + Pap screen + ++ SunSmart +++ +++ Pre-diabetes Screen + dietary advice + ++ Screen + exercise physiologist ++ ++ ++ ++ Screen + dietary advice & exercise physiologist ++ ++ Screen + metformin ++ ++ Screen + acarbose Kidney Proteinuria screen & ACE-inhibitor for ++ ++ disease non-diabetics >25 yrs Mental Screening & group CBT pre-depression + ++ disorders Screening & CBT post-partum depression + +

Interventions >$50,000/DALY Not cost-effective Other reasons to select? 23

Topic area Interventions Comment Diet F&V interventions targeting Poor effectiveness individuals and at workplace Dietary advice on salt Poor effectiveness Weight watchers Poor maintenance of weight loss Multi-component diet/physical Poor effectiveness activity/weight intervention Orlistat, sibutramine Too expensive Osteoporosis Raloxifene Too expensive Mental health / School based drug intervention Poor effectiveness drugs / suicide Gun buy- back scheme Poor evidence; high cost Pre-diabetes Orlistat and rosiglitazone Too expensive Vision loss Ranibizumab for macula degeneration Too expensive Shingles Varicella vaccination at age 50 Too expensive/low frequency

Insufficient evidence of effectiveness : Dental check-ups Screen vision loss general population Emergency cards for people who attempted suicide Aspirin Front of pack traffic light nutrition labelling Roadside drug testing More harm than good : PSA testing for prostate cancer 25

‘Benchmark’ interventions Treatment or infectious disease control Selected results 26