FLURESP Cost-Effectiveness of Public Health Interventions against Human Influenza. Ariel Beresniak, MD, MPH, PhD Fluresp Project Leader

Transcription

1 FLURESP Cost-Effectiveness of Public Health Interventions against Human Influenza Ariel Beresniak, MD, MPH, PhD Fluresp Project Leader

2 FLURESP European consortium

3 FLURESP is the first and only project assessing cost-effectiveness of various public-health measures against human influenza Litterature: 44 economic evaluations of pandemic preparedness 34 focused exclusively on pharma interventions (vaccines and Antivirals) Only 4 studies focused on one of the non-pharma interventions School closures Air travel restrictions Sick leave authorizations Face masks Poor methodology Limited to of one single epidemic scenario Limitation of costs data Poor uncertainty management Use of QALY / DALY

4 Cost-consequences Analyses Cost-Benefit Analysis (CBA) Both criteria are expressed in monetary units Absolute cost-benefit analysis Relative cost-benefit analysis Cost-Effectiveness Analysis (CEA) One criterion is expressed in monetary unit (cost) One criterion is expressed in natural physical units (clinical effectiveness) Mean cost-effectiveness analysis Incremental cost-effectiveness analysis Cost-Utility Analysis (CUA) One criterion is expressed in monetary units (cost) One criterion is expressed in utility units Mean cost-utility analysis Incremental cost-utility analysis Costs/QALY or Costs/DALY

5 General Confusion Between CEA and CUA! Cost-utility analyses often incorrectly presented as costeffectiveness analyses, where effectiveness criteria = QALY High cost/qaly results often presented as cost-ineffective Misleading terminology

6 Cost-Effectiveness and the QALY controversy Quality Adjusted Life Years = Time x Quality of Life (utility) 2 years at 0.5 utility = 1 year at 1 utility 10 years at 0.2 utility = 2 years at 1 utility

7 Divergent QALY/DALY Using the Same Dataset! 2 days in Oslo versus 1 day in Rome? QALY = Time x Temp ( o C) OSLO 2 days x 5 o C = 10 QALY MALTA 1 day x 25 o C = 25 QALY QALY = Time x Temp ( o F) OSLO 2 days x 41 o F = 82 QALY MALTA 1 day x 77 o F = 77 QALY Recommendation. QALY and DALY outcomes should be abandonned

8 FLURESP Cost-Effectiveness analyses Main features 18 interventions (pharma and non-pharma) 6 pandemic scenarios 2 effectiveness criteria Non QALY based Epidemiologically meaningfull: Costs per success Costs to achieve 40% reduction of mortality Costs to achieve 30% reduction of morbidity 4 target countries France Italy Poland Romania Possibility to assess sequential strategies

9 18 interventions 1. Individual measures 2. Border control measures 3. Community control measures 4. Protection measures in existing health care facilities 5. Protection measures in specific health care facilities 6. Vaccination at-risk population existing organizations 7. Vaccination at-risk population specific organizations 8. Vaccination health professionals existing organizations 9. Vaccination health professionals specific organizations 10. Vaccination general population existing organizations 11. Vaccination general population specific organizations 12. Antiviral prophylactic distribution 13. Antiviral curative distribution 14. Antibiotherapy guidelines 15. Pneumococcal vaccination 16. Development of new ICU capacity 17. Development of ECMO 18. Screening measures

10 6 pandemic levels Scenario A: seasonal flu Scenario B: 2009 pandemic like Scenario C: community risk / low virulance Scenario D: community risk / high virulance Scenario E: high risk groups / age cases Scenario F: major event

11 Robust uncertainty management Uniform distribution ranges costs data: intervention costs + communication costs effectiveness data Probability to achieve 40% reduction of mortality Probability to achieve 30% reduction of morbidity Monte carlo simulations high quality random generator simulation

12 Huge number of FLURESP cost-effectiveness analyses 18 interventions 6 pandemic scenarios 4 countries 2 effectiveness criteria 864 cost-effectiveness ratios!

13 Assessment of Sequential strategies: Various combinations of public-health measures 1st line 2d line 3rd line A: B: C : D: 13

14 Mortality criteria: most cost-effective : ECMO Scenario A: Scenario B: Scenario C: Scenario D: Scenario E: Scenario F: /Success /Success /Success /Success /Success /Success

15 Mortality criteria: very cost-effective : Guidelines antibiotherapy Scenario A to F: /Success

16 Mortality criteria: less cost-effective : Screening measures Scenario A to F: /Success

17 Mortality criteria Curative antiviral distribution more cost-effective than prophylactic distribution Curative antiviral distribution Scenario A: /S Scenario B: /S Scenario C: /S Scenario D: /S Scenario E: /S Scenario F: /S Prophylactic antiviral distribution Scenario A: /S Scenario B: /S Scenario C: /S Scenario D: /S Scenario E: /S Scenario F: /S

18 Morbidity criteria Vaccination of general population more cost-effective than vaccination of at-risk groups Vaccination general population Scenario A, B, C, D, E, F: /S Vaccination At-risk group Scenario A, B, C, D, E, F: /S

19 FLURESP Recommendation Targeting the general population is more cost-effective for implementing vaccination programs whatever the level of severity of the outbreak

20 What evidence behind recommendations to vaccine priority groups? WHO expert groups use to recommend priority groups for budgeting reasons, but without any economical evidence! Budget Economics FLURESP provides the first European evidence of economical advantage of mass vaccination The financial excuse should not be a barrier anymore for improving vaccination coverage

21 Whats next? Dissemination of FLURESP approach and results Assessment of other key European countries Assessment of most efficient sequential public health measures Adaptation of FLURESP approach to other health threats