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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
5
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’
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
9
League table
10
11
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
12
Results: cost-effectiveness plane
$50,000/DALY threshold
Volumetric
13
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
++
++
+
+++
+++
+
14
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
+ +
17
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 of childhood anxiety disorders
+ +
Other Universal infant HBV vaccination + ++
20
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 + +
23
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
25
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
26
‘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
28
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!)
29
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
31
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)
32
Intervention pathways: ‘Ideal mix’
33
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Alcohol
-$600
-$500
-$400
-$300
-$200
-$100
$0
$100
- 20 40 60 80 100 120 140
Net
lifet
ime
cost
s (m
illio
ns A
US$
200
3) 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
$00 10 20 30 40 50 60 70
Net l
ifetim
e co
st (m
illio
nsAU
S$20
03)
Lifetime DALYs averted (thousands)
Pedometers
GP referralMass media
Internet
GP prescription
TravelSmart
Pre-diabetes screening + lifestyle intervention/ drugs
0
200
400
600
800
1000
1200
0 5000 10000 15000 20000 25000 30000
Tota
l Cos
t ($
mill
ion)
Health Benefits (DALYs)
Diet & ExerciseMetformin$50,000/DALY
36
Blood pressure & cholesterol lowering
37
Phytosterol + Statin+Ezetimibe
≥5%
CCB + ACEi ≥5% + Phytosterol ≥10%
Diuretic+ Dietitian+ Phytosterol ≥5%
Diuretic+ CCB + Dietitian ≥10%
Diuretic+ CCB + Dietitian
≥15%
Diuretic ≥10% CHHP
Diuretic ≥15%
Current practice
- 5,000
-
5,000
10,000
15,000
20,000
25,000
- 100 200 300 400 500 600
Net
Life
time
Cost
s (m
illio
n AU
S$ 2
003)
Lifetime DALYs averted ('000)
38
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
Life
time
Cost
s (m
illio
n AU
S$ 2
003)
Lifetime DALYs averted ('000)
39
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
0 20 40 60 80 100 120 140
Net
life
time
cost
s (2
008A
$)B
illio
ns
Lifetime DALYs averted or QALYs gainedThousands
$50,000/DALY or QALY
Cost per year for 40 mg generic simvastatin: Australia: $400 New Zealand: <$20
40
-4,000
-3,000
-2,000
-1,000
00 50 100 150 200 250 300
Net
life
time
cost
s (m
illio
n A
US
$) Lifetime DALYs averted (thousands)
Tax
Lapband
Diet & exercise
Weight loss
41
Dialysis & transplant (current practice)
DM ( 50-79)
Dialysis only
- 200
0
200
400
600
800
5,000 10,000 15,000 20,000
Net
LIfe
time
Cost
(mill
ion
AU$
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
42
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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
44
Reminder of key results 4. Emerging evidence for a substantial role in prevention
of mental disorders 5. Targeted interventions with drug treatments in CVD
prevention, pre-diabetes, chronic kidney disease, osteoporosis good credentials
6. Targeted interventions aiming to change behaviour tend not to be cost-effective and if so, have modest impact on population health
45
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
