The Economics of Prevention AHIA conference Sydney, 9 November 2010

Transcription

1 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

2 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 ( ) 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

4 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 Mental disorders Cardiovascular disease 1 5 Other Total

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 5

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

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

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 2 nd stage filters (equity; acceptability; feasibility; size of the problem) Plus confidence in evidence base 8

9 Results 9

10 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, Dominant Volumetric taxation 11, Dominant Advertising bans 7, Dominant Minimum drinking age Dominant Licensing controls 2, ,300 Brief intervention ,800 Brief intervention + telemarketing ,000 Random breath testing 2, ,000 Drink drive mass media 1, ,000 Residential treatment & naltrexone ,000 Residential treatment ,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:

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

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, Medium 10, , Large >100,000 DALYs Intervention cost (annual) + Small <10 ++ Medium Large >100 $million 13

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

15 Topic area Intervention Lifetime health impact Annual intervention cost Alcohol Volumetric tax ++ + Tax increase 30% Advertising bans + + Minimum legal drinking age to 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

16 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 ultrahigh risk for psychosis Oral health Fluoridation drinking water nonremote areas

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

18 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 retailored + + Body mass Gastric banding

19 Topic area Intervention Lifetime health impact Annual intervention cost BP & chol Low dose diuretics >5% CVD risk Mental disorders, drugs, suicide Polypill $200 to over 55s Calcium channel blockers >10% CVD risk ACE-inhibitors >15% CVD risk + ++ 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 20

21 Lifetime health impact Annual intervention cost Topic area Intervention 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

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

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

24 Topic area Interventions Comment Diet F&V interventions targeting individuals and at workplace Dietary advice on salt Weight watchers Multi-component diet/physical activity/weight intervention Orlistat, sibutramine Poor effectiveness Poor effectiveness Poor maintenance of weight loss Poor effectiveness Too expensive Osteoporosis Raloxifene Too expensive Mental health / drugs / suicide School based drug intervention Gun buy- back scheme Poor effectiveness 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 25

26 Benchmark interventions Treatment or infectious disease control Selected results 26

27 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 Good buys Knee replacement for osteoarthritis $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 ++ ++

28 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

29 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

30 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 30

31 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

32 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

33 Intervention pathways: Ideal mix 33

34 Alcohol $100 Current practice $ Net lifetime costs (millions AUS$ 2003) -$100 -$200 -$300 -$400 Volumetric tax Lifetime DALYs averted (thousands) Res. treat. + naltrexone RBT -$500 30% tax Drink drive mass media -$600 Ad bans Min. legal drinking age to 21 yrs Licensing controls Brief intervention 34

35 Physical inactivity $0 Lifetime DALYs averted (thousands) Net lifetime cost (millionsaus$2003) -$200 -$400 -$600 -$800 Pedometers Mass media GP prescription TravelSmart GP referral Internet -$1,000 35

36 Pre-diabetes screening + lifestyle intervention/ drugs 1200 Diet & Exercise Metformin 1000 $50,000/DALY 800 Total Cost ($ million) Health Benefits (DALYs) 36

37 25,000 20,000 Blood pressure & cholesterol lowering Phytosterol + Statin+Ezetimibe 5% Net Lifetime Costs (million AUS$ 2003) 15,000 10,000 5, ,000 CHHP Diuretic 15% Diuretic 10% Diuretic+ CCB + Dietitian 10% Diuretic+ CCB + Dietitian 15% Current practice Diuretic+ Dietitian+ Phytosterol 5% CCB + ACEi 5% + Phytosterol 10% Lifetime DALYs averted ('000) 37

38 25,000 20,000 Blood pressure & cholesterol lowering Statin+Ezetimibe 5% Net Lifetime Costs (million AUS$ 2003) 15,000 10,000 5,000-5,000 CHHP Polypill 15% Polypill 10% Current practice Polypill 5% Dietitian 5% Phytosterol 5% Diuretic + CCB + ACEi 5% Lifetime DALYs averted ('000) 38

39 Net lifetime costs (2008A$) Billions Blood pressure & cholesterol lowering $3.0 $2.5 $2.0 $1.5 $1.0 $0.5 $0.0 -$0.5 Diuretic 15% $50,000/DALY or QALY Cost per year for 40 Statin mg 10-14% generic simvastatin: Australia: $400 New Zealand: <$20 ACEi 10-14% ACEi 15% CCB 10-14% CCB 15% Diuretic 10-14% Statin 15% ACEi10-14% ACEi 15% CCB10-14% CCB 15% StatinNZ 15% StatinNZ10-14% Diuretic 15% Diuretic10-14% Thousands Lifetime DALYs averted or QALYs gained 39

40 Weight loss Net lifetime costs (million AUS $) 0-1,000-2,000-3, Lifetime DALYs averted (thousands) Diet & exercise Lapband -4,000 Tax 40

41 800 Chronic Kidney disease Dialysis only Dialysis & transplant (current practice) 600 Screening and early treatment Net LIfetime Cost (million AU$ 2003) DM ( 50-79) Non-DM ( 50-79) Non-DM ( 40-49) Non-DM ( 25-39) 5,000 10,000 15,000 20,000 DM DM ( 25-39) ( 40-49) Lifetime DALYs averted

42 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

43 Reminder of key results 1. Taxation/regulation interventions tend to be very costeffective (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 43

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 44

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 45