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

3

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

4

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

Topic areas and interventions

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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

• bjectives and concept of ‘benefit’

6

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

7

C/E analysis protocol (Pamphlet C)

Outcomes Cost per DALY saved + 2nd stage filters 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; 2nd stage filters & implications

8

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 ‘2nd stage filters’ (equity; acceptability;

feasibility; size of the problem)

• Plus confidence in evidence base

Results

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League table

10

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DALYs, costs & cost-effectiveness ratios for alcohol interventions

DALYs Intervention 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

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Results: cost-effectiveness plane

$50,000/DALY threshold

Volumetric

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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 (lifetime) Small 0–10,000 Medium 10,000–100,000 Large >100,000 DALYs Intervention cost (annual) Small <10 Medium 10–100 Large >100 $million

++ ++ +

+++

+++

+

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Dominant interventions

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

Topic area Intervention Lifetime health impact Annual intervention 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 +++ +++

Topic area Intervention Lifetime health impact Annual intervention 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 + +

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Interventions < $10,000/DALY Very good buys

Topic area Intervention Lifetime health impact Annual intervention 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 +++ +++

Topic area Intervention Lifetime health impact Annual intervention 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 disorders, drugs, suicide Screen & bibliotherapy minor depression adults + ++ 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

• f childhood anxiety disorders

+ + Other Universal infant HBV vaccination + ++

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

Topic area Intervention Lifetime health impact Annual intervention 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

+++ +++

Topic area Intervention Lifetime health impact Annual intervention 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 disease Proteinuria screen & ACE-inhibitor for non-diabetics >25 yrs

++ ++

Mental disorders Screening & group CBT pre-depression

+ ++

Screening & CBT post-partum depression

+ +

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

Topic area Interventions Comment

Diet F&V interventions targeting individuals and at workplace Poor effectiveness Dietary advice on salt Poor effectiveness Weight watchers Poor maintenance of weight loss Multi-component diet/physical activity/weight intervention Poor effectiveness Orlistat, sibutramine Too expensive Osteoporosis Raloxifene Too expensive Mental health / drugs / suicide School based drug intervention Poor effectiveness 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

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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

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‘Benchmark’ interventions Treatment or infectious disease control Selected results

Topic area Intervention Lifetime health impact Annual intervention cost

Dominant Net cost savers

HIV Needle exchange program +++ ++

Very cost-effective <$10,000/DALY

CVD Rehabilitation after myocardial infarction + ++ HIV Circumcision all Men having Sex with Men + ++ Osteoarthritis Hip replacement for osteoarthritis +++ +++ Knee replacement for osteoarthritis +++ +++

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

Breast cancer Trastuzumab for early breast cancer, 9 week course + ++ CVD Early stenting for myocardial infarction + +++ Angioplasty coated stents in diabetics + ++

Cost-ineffective >$50,000/DALY

Alcohol Residential treatment +/- naltrexone + ++ Renal disease Dialysis & transplant ++ +++ CVD Bypass and stents vs medical treatment + +++ HIV Early antiretrovirals ++ ++

Results for 123 prevention measures:

• 23 net cost saving
• 20 very cost-effective <$10,000 per healthy life year (DALY)
• 31 cost-effective $10-50,000 per DALY
• 38 not cost-effective
• 2 more harm than good; 2 for which better alternatives
• 4 insufficient evidence of effectiveness

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Very cost-effective and large health impact:

• Tax alcohol, tobacco and ‘unhealthy food’
• Regulation of salt content in bread, cereals and margarine
• Treating blood pressure and cholesterol …. but doing this

more efficiently than we currently do

• using cheaper drugs
• better targeting who needs to be treated
• Gastric banding for the very obese (but expensive!)

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Very cost-effective and moderate health impact:

• Pedometers & mass media for physical activity
• Smoking cessation drugs
• Screen elderly women for osteoporosis & alendronate
• Screen diabetics for chronic kidney disease

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Very cost-effective & more modest health impact:

• Fluoride drinking water
• Hepatitis B vaccination
• A range of 7 measures to prevent mental disorders or suicide

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Other cost-effective measures:

• Increased SunSmart effort
• HPV vaccination and Pap smear testing cervix cancer
• Screen for pre-diabetes + drug or lifestyle intervention
• Screen for chronic kidney disease + drug
• Diet and exercise for overweight people (but limited

impact on weight loss)

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Intervention pathways: ‘Ideal mix’

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Alcohol

• $600
• $500
• $400
• $300
• $200
• $100

$0 $100

• 20

40 60 80 100 120 140 Net lifetime costs (millions AUS$ 2003) Lifetime DALYs averted (thousands)

Ad bans RBT Drink drive mass media

• Res. treat. +

naltrexone Licensing controls

• Min. legal drinking age to 21 yrs

Brief intervention 30% tax Current practice Volumetric tax

Physical inactivity

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• $1,000
• $800
• $600
• $400
• $200

$0 10 20 30 40 50 60 70 Net lifetime cost (millionsAUS$2003) Lifetime DALYs averted (thousands) Pedometers GP referral Mass media Internet GP prescription TravelSmart

Pre-diabetes screening + lifestyle intervention/ drugs

200 400 600 800 1000 1200 5000 10000 15000 20000 25000 30000 Total Cost ($ million) Health Benefits (DALYs) Diet & Exercise Metformin $50,000/DALY

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Blood pressure & cholesterol lowering

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Phytosterol + Statin+Ezetimibe ≥5% CCB + ACEi ≥5% + Phytosterol ≥10% Diuretic+ Dietitian+ Phytosterol ≥5% Diuretic+ CCB + Dietitian ≥10% Diuretic+ CCB + Dietitian ≥15% Diuretic ≥10%

CHHP

Diuretic ≥15% Current practice

• 5,000
• 5,000

10,000 15,000 20,000 25,000

• 100

200 300 400 500 600

Net Lifetime Costs (million AUS$ 2003) Lifetime DALYs averted ('000)

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Blood pressure & cholesterol lowering

CHHP Polypill ≥ 15% Polypill ≥ 10% Polypill ≥ 5% Dietitian ≥ 5% Phytosterol ≥ 5% Diuretic + CCB + ACEi ≥5% Statin+Ezetimibe ≥5% Current practice

• 5,000

5,000 10,000 15,000 20,000 25,000 100 200 300 400 500 600

Net Lifetime Costs (million AUS$ 2003) Lifetime DALYs averted ('000)

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Blood pressure & cholesterol lowering

Diuretic ≥15% Diuretic 10-14% CCB ≥15% CCB 10-14% ACEi ≥15% ACEi 10-14% Statin ≥15% Statin 10-14% ACEi10-14% ACEi≥15% CCB10-14% CCB≥15% Diuretic10-14% Diuretic≥15% StatinNZ10-14% StatinNZ≥15%

• $0.5

$0.0 $0.5 $1.0 $1.5 $2.0 $2.5 $3.0 20 40 60 80 100 120 140

Net lifetime costs (2008A$) Billions Lifetime DALYs averted or QALYs gained Thousands

$50,000/DALY or QALY

Cost per year for 40 mg generic simvastatin: Australia: $400 New Zealand: <$20

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• 4,000
• 3,000
• 2,000
• 1,000

50 100 150 200 250 300 Net lifetime costs (million AUS $) Lifetime DALYs averted (thousands) Tax Lapband Diet & exercise

Weight loss

41 Dialysis & transplant (current practice) DM ( 50-79) Dialysis only

• 200

200 400 600 800 5,000 10,000 15,000 20,000 Net LIfetime Cost (million AU$ 2003) Lifetime DALYs averted Screening and early treatment DM ( 40-49) DM ( 25-39) Non-DM ( 50-79) Non-DM ( 40-49) Non-DM ( 25-39)

Chronic Kidney disease

Blue print for governments:

• good investments in prevention that are

affordable

• opportunities for large health improvement
• potential to reduce wasteful spending

Governments will need strong arguments to ignore the compelling evidence

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Reminder of key results

1. Taxation/regulation interventions tend to be very cost- effective (from health sector perspective) and have large health impact 2. Great potential to improve efficiency in CVD prevention thru blood pressure and cholesterol lowering and accelerate CVD decline 3. Untapped potential to address pre-diabetes, chronic kidney disease

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Reminder of key results

4. Emerging evidence for a substantial role in prevention

• f mental disorders

5. Targeted interventions with drug treatments in CVD prevention, pre-diabetes, chronic kidney disease,

• steoporosis good credentials

6. Targeted interventions aiming to change behaviour tend not to be cost-effective and if so, have modest impact

• n population health

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Dissemination of results



Written documents:

• Intervention briefing papers (standard format)
• Project report
• Journal articles
• 26 brief 4-8 page pamphlets on various aspects of project and

results by topic area



Presentations:

• Road shows; Conferences; Workshops



Website http://www.uq.edu.au/bodce-ace-prevention