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Collaborators and acknowledgements
Dr Nick Cavill (National Obesity Observatory) Dr Harry Rutter (LSHTM) Hywell Dinsdale (National Obesity Observator) Funded by Department of Health Expert panel:Alastair Fisher NICE
Peter Dick, DH
Ric Fordham, University of East Anglia
Phil James, IOTF/IOASO
Carolyn Summerbell, University of Durham
Louise Woolway, NHS Somerset
Adrian Coggins, West Essex PCT
Corinna Hawkes,
Lesley Manning, Buckinghamshire PCT
William Hollingworth, University of Bristol
Carol Weir, Sheffield PCT
Background
Limited evidence on c-e of weight/obesity interventions/programmes
Practical problem of funding being allocated to those programmes where evidence base is strong
Call for decision aid/tool to help make these resource allocation decisions in the area of obesity/overweight
Development of National Obesity Observatory (NOO) economics/cost-effectiveness tool –
NOO e-tool
AIM: To help the public health community (namely commissioners involved with commissioning public health interventions) make informed decisions about the commissioning of obesity interventions through a practical guide/e-tool on the cost-effectiveness and cost/economic impact of interventions.
Objectives
1.To conduct a rapid review of methods and tools used by other agencies/analysts when making resource allocation decisions related to obesity and overweight interventions.
2.Advise on options for approaches for development of practical tool: To refine and agree a recommended approach to providing pragmatic cost-effectiveness estimates for obesity /overweight programmes/interventions at a local level
3.To develop, test and launch a practical tool based on this agreed approach
Wish List:
The e-tool should address the need for information on the cost effectiveness of interventions that are likely to be of value in preventing/reducing obesity in the local population.
It should bring together the available data, evidence and best practice relating to cost effectiveness into one resource.
Be accessible and easy to use Transparent and evidence based Enable users to input their own data and
assumptions
Overview of research plan:
Rapid review of the literature• The aim of the rapid review is to provide information on
what tools are currently being used to save the potential of replication.
Tool development and production• Starting point for the tool development, two or three
interventions will be chosen where the evidence-base in terms of effectiveness and associated costs have been well defined. This will provide a benchmark for the tool development and define what such a tool could provide in terms both the inputs and outputs.
E-tool testing and refinement• Use of user friendly transparent platform for development
and testing (Excel)• Refinement – translate into web-based platform?• Testing – using expert panel and HERC and NOO
researchers.
Rapid review – review of reviews
The literature search resulted in 517 potential publications.
Full text review of 32 reports/reviews Resulted in 22 of interest Additional 8 reports/toolkits not from
literature search n=30 reports/reviews/toolkits
Rapid review – types of review study
Reviews of the literature on economic evaluation of programmes/interventions aimed at obesity overweight n=10
Primary study using effectiveness review to inform cost-effectiveness ratios (Wu 2011) defined cost per MET hour (ratio of expended energy/resting energy based on body size)
Review of economic evaluation plus model development (HTA 2011 (15)44, HTA 2004 (8)21, Jacobs van der Bruggen et al. 2009).
Model/toolkit n=8 (Cecchini 2010 (OECD), Carter 2009, Haby 2006, Forster 2010 (ACE-Obesity), Mernagh (NZHTA) 2010, Roux 2008, Galani 2007, Bemelmans 2008)
Additional reports/toolkits
Health England Leading Prioritisation (H.E.L.P) online tool MATRIX -provides cost-effectiveness, impact on health inequalities and reach of 17 interventions (comprising programmes related to alcohol use, mental health, obesity)
Foresight 2007. (McPherson K, Marsh T, Brown M. Foresight: Tackling Obesities: Future Choices – Modelling Future Trends in Obesity and the Impact on Health. 2007)
WSIPP (Washington State Institute for Public Policy. An Economic Model to Inform Investment Decisions made by Central and Local Government. 2012. Social Research Unit)
Brunel/Nottingham tobacco control model (HERG Brunel University, QMC Nottingham University, London Health Observatory. Building the business case for Tobacco Control. A toolkit to estimate the economic impact of tobacco. 2011).
Department of Education Family Savings Calculator (http://www.c4eo.org.uk/costeffectiveness/supportdelivery.aspx )
NICE Clinical Guideline 43 (NICE. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guidedline CG43. 2006).
ScHARR diabetes prevention model (Gillett M, Brennan A, Blake L. Prevention of type2 diabetes: preventing pre-diabetes among adults in high-risk groups. Report on use of evidence from effectiveness reviews and cost-effectiveness modelling. 2010. NICE Public Health Collaborating Centre)
Final useful models
Sassi / OECD ACE Mernagh (Van Baal) Ara HTA 2012 16(5) (updated HTA report on
interventions for obesity) HELP - Matrix Smoking Cessation – Brunel developed for
NICE WSIPP C4EO
Challenges to the development of the e-tool:
1) Scope of cost inputs Interventions aimed at tackling overweight and obesity
have the following economic costs: To the health sector via the health care system for
treatment of obesity and its complications, intervention costs e.g. equipment, training, materials, clinician visits etc, health care costs related to diseases and complications resulting from obesity/overweight.
To the individual in terms of time spent undertaking lifestyle/behavioural intervention, out of pocket expenses (e.g. equipment, clothing etc).
Intersectoral impacts: social care, criminal justice, voluntary, education, housing, transport, environment
To society in terms of lost workdays (absenteeism) and loss of productivity while at work (presenteeism) .
Costs of health conditions
Healthcare costs of condition x (£ per year)
Does this change by time since diagnosis?
Changes by sex and age?
Effects of comorbidities?
Costs of Diabetes: Comparison of Ara (2012), Forster (2011), Van Baal
(2008)
Challenges to the development of the e-tool:
2) Scope of outcomes Economic outcomes from the rapid review ranged
from: productivity based-absenteeism life years gained and survival -combined with measures of quality of life/wellbeing
in the form of DALYs and QALYs (although utility measures tended to come from 1-2 sources – DA from WHO-CHOICE, QA from Macran and HSE
simplistic clinical measures such as MET hours (ratio of expended energy/resting energy, based on body size), BMI, activity levels, body weight, cholesterol level
Numbers of individuals with chronic disease (CVD, stroke, diabetes, cancer)
Challenges to the development of the e-tool: 3) Link between intervention impact on clinical and economic
outcome
How to establish the link between the intervention impact on intermediate outcomes and long-term quality of life and mortality outcomes (LY gained, QALY’s DALYs).
In general this was undertaken using Markov, simulation or disease models and using clinical outcomes e.g. BMI, potential impact fractions (PIFs), MET hours of energy expended, levels of overweight etc to predict disease conditions such as CVD, cancer, diabetes etc and using the diseases as a vehicle for health care costs, productivity losses and utility measures/survival.
Requires evidence base to inform modelling risk equations
RR estimates for diabetes among obese individuals:
Comparison of NAO (2001), Van Baal (2008), Forster (2011)
RR estimates for diabetes among obese individuals:
Ara (2012)
Challenges to the development of the e-tool:
4) Time horizon All the models in the rapid review used a lifetime horizon Except n=1 (Bemelmans 2008) who used a 20 and 80 year follow
up period All additional reports/models use lifetime horizon apart from
Tobacco control toolkit where model outputs are split analysis into 3-time horizons:• Short-term outcomes (2 years): GP and practice nurse consultations,
outpatient attendances, prescriptions, hospital admissions, numbers of people with smoking related disease
• Medium term (10 years): costs of smoking related conditions (lung cancer, CHD, COPD, MI and stroke), productivity losses.
• Long-term (lifetime): number of deaths and life years, treatment costs, QALYs.
DoE savings calculator –SROI(social return on investment) over life time or shorter periods e.g. 2 yrs
Commisssioners work to shorter time-horizons and want to know how their current investment in obesity interventions will impact on costs and outcomes in the next 1-2 years
Challenges to the development of the e-tool:
5) consider a portfolio of interventions? In practice obesity interventions are rarely
commissioned in isolation.
All reviews/models from rapid review explore interventions in isolation
Problem is how to model the correlation between the interventions and the impact they may collectively have on obesity
Challenges to the development of the e-tool:
6) Maintenance of impact of intervention ? Assumptions need to be made concerning the
maintenance or decay in impact of intervention
Cecchini et al, assumed the impact of the intervention to disappear once exposure to the intervention ends
ACE-obesity assumed 100% of benefits to be maintained over the lifetime of the model
Mernagh and colleagues assumed a reduction in BMI relative to control to decay by 1% per annum over the lifespan of the model after the 5th year following the initiation of the intervention
Challenges to the development of the e-tool:
7) Impact of intervention Reduction in BMI (mean? Mean & SD? %
moving from obese to overweight?) How long before this weight loss is achieved?
(years? Years & months?) How long is this weight loss maintained?
(years? years & months?) Duration of intervention? Uptake period for intervention (number of
years before full build up)? Drop out rate? (% per year?)
Additional challenges
Availability of data to populate the model – local v national data
Use of sensitivity/what-if analysis - this was used widely in the models found in the rapid review, but tended not to be used in toolkits.
Systematic approach?2 different approaches?
NICE: time horizon so as to incorporate all important costs and effects – usually lifetime, CUA (CCA and CBA secondary analysis), NHS/PSS or public sector perspective (productivity costs excluded), use of sensitivity analysis. National level evaluation.
Commissioners: 1-2 year time horizon (also interested in lifetime impacts), outcomes (broader perspective)– impact on clinical indicators of obesity, BMI, related diseases etc, public sector impacts and costs NHS/PSS and other sectors, business costs – productivity. Use of sensitivity and what-if analysis. Local level evaluation.
Over to you – wish list
Is it the local level you require? Or do you need more?
Are we trying to be too ‘all encompassing’?
What are the key costs/outcomes/benefits you require to make your case?
